Basic Information
| Provider Information | |||||||||
| NPI: | 1043623648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR LARSEN EYE CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3025 W 75 N | ||||||||
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| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840415747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015139951 | ||||||||
| FaxNumber: | 8017799942 | ||||||||
| Practice Location | |||||||||
| Address1: | 7071 N 138TH AVE # 1552 | ||||||||
| Address2: | |||||||||
| City: | LUKE AFB | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853072006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235360332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2014 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8015139951 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 375876-9934 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.