Provider Demographics
NPI:1811466212
Name:LARS VAN ETTEN MD LLC
Entity type:Organization
Organization Name:LARS VAN ETTEN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ETTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-242-5811
Mailing Address - Street 1:334 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1032
Mailing Address - Country:US
Mailing Address - Phone:719-242-5811
Mailing Address - Fax:
Practice Address - Street 1:25 MONTEBELLO RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1236
Practice Address - Country:US
Practice Address - Phone:719-544-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty