Provider Demographics
NPI:1457419863
Name:LARSON CHIROPRACTIC OFFICE INC
Entity Type:Organization
Organization Name:LARSON CHIROPRACTIC OFFICE INC
Other - Org Name:RANDY O LARSON DC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:OBERT
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-635-9307
Mailing Address - Street 1:410 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801
Mailing Address - Country:US
Mailing Address - Phone:715-635-9307
Mailing Address - Fax:
Practice Address - Street 1:410 N RIVER ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801
Practice Address - Country:US
Practice Address - Phone:715-635-9307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1432012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
350052432OtherRR MEDICARE
WI38752600Medicaid
WI38752600Medicaid
350052432OtherRR MEDICARE