Provider Demographics
NPI:1477301786
Name:LARSEN, ROY WALTER JR
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:WALTER
Last Name:LARSEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 KENDIS STREET
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948
Mailing Address - Country:US
Mailing Address - Phone:941-889-7447
Mailing Address - Fax:
Practice Address - Street 1:2031 KENDIS STREET
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948
Practice Address - Country:US
Practice Address - Phone:941-369-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant