Provider Demographics
NPI:1649495433
Name:LARSON, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:2147 OVERLAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6478
Mailing Address - Country:US
Mailing Address - Phone:406-655-0101
Mailing Address - Fax:406-655-0032
Practice Address - Street 1:2147 OVERLAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6478
Practice Address - Country:US
Practice Address - Phone:406-655-0101
Practice Address - Fax:406-655-0032
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT205171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist