Provider Demographics
NPI:1649921776
Name:LARSON, P. RENE
Entity type:Individual
Prefix:
First Name:P.
Middle Name:RENE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:LEAD
Mailing Address - State:SD
Mailing Address - Zip Code:57754-1007
Mailing Address - Country:US
Mailing Address - Phone:605-641-3467
Mailing Address - Fax:
Practice Address - Street 1:301 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:LEAD
Practice Address - State:SD
Practice Address - Zip Code:57754-1007
Practice Address - Country:US
Practice Address - Phone:605-641-3467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9B1243347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle