Basic Information
| Provider Information | |||||||||
| NPI: | 1295362614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN-HALLOCK | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 VERSAILLES RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592574890 | ||||||||
| FaxNumber: | 8593231123 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 VERSAILLES RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592574890 | ||||||||
| FaxNumber: | 8593231123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.