Provider Demographics
NPI:1881757722
Name:LARSON, LISA ANN (DC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BROADWATER SQ
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-1634
Mailing Address - Country:US
Mailing Address - Phone:406-259-4393
Mailing Address - Fax:406-896-1245
Practice Address - Street 1:901 BROADWATER SQ
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1634
Practice Address - Country:US
Practice Address - Phone:406-259-4393
Practice Address - Fax:406-896-1245
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT676111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT04-01157-3OtherSTATE FUND
MT40251OtherBLUE CROSS BLUE SHIELD
MT40251OtherBLUE CROSS BLUE SHIELD
MT000084500Medicare PIN
MT000004636Medicare PIN