Healthcare Provider Details

I. General information

NPI: 1508189853
Provider Name (Legal Business Name): LARSON REHABILITATION SERVICES, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W UNIVERSITY AVE STE 106
FLAGSTAFF AZ
86001-3114
US

IV. Provider business mailing address

1600 W UNIVERSITY AVE STE 106
FLAGSTAFF AZ
86001-3114
US

V. Phone/Fax

Practice location:
  • Phone: 928-526-3031
  • Fax: 928-526-3098
Mailing address:
  • Phone: 928-526-3031
  • Fax: 928-526-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number5758
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5758
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ZANE LARSON LARSON
Title or Position: MEMBER
Credential: PT, DPT, ECS, OCS
Phone: 928-526-3031