Basic Information
| Provider Information | |||||||||
| NPI: | 1144426164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSSON | ||||||||
| FirstName: | BENGT | ||||||||
| MiddleName: | GOSTA | ||||||||
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| Credential: | MS, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 PHILADELPHIA ST | ||||||||
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| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157013902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244637478 | ||||||||
| FaxNumber: | 7244630931 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 EGYPT RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | TROOPER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194032317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106661702 | ||||||||
| FaxNumber: | 6106661726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT017643 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.