Provider Demographics
NPI:1669596821
Name:CHAN, LARRY (LMT, CNMT)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1517
Mailing Address - Country:US
Mailing Address - Phone:719-432-8477
Mailing Address - Fax:719-227-0303
Practice Address - Street 1:923 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1517
Practice Address - Country:US
Practice Address - Phone:719-432-8477
Practice Address - Fax:719-227-0303
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1330171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1330OtherCITY OF MANITOU SPRINGS