Healthcare Provider Details

I. General information

NPI: 1245327394
Provider Name (Legal Business Name): SAMUEL LARSEN HALLOWS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 01/19/2020
Certification Date: 01/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6750 E MAIN ST STE 108
MESA AZ
85205-9049
US

IV. Provider business mailing address

7165 E UNIVERSITY DR STE 102
MESA AZ
85207-6400
US

V. Phone/Fax

Practice location:
  • Phone: 480-985-0720
  • Fax:
Mailing address:
  • Phone: 480-985-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7764
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4447
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: