Provider Demographics
NPI:1841265956
Name:LARSON, DOUGLAS J (DC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:LARSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 5TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-6031
Mailing Address - Country:US
Mailing Address - Phone:605-892-4845
Mailing Address - Fax:
Practice Address - Street 1:1515 5TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-6031
Practice Address - Country:US
Practice Address - Phone:605-892-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7602992Medicaid
SD7602992Medicaid
SDS86538Medicare PIN
SD86538Medicare ID - Type Unspecified