Healthcare Provider Details

I. General information

NPI: 1316175607
Provider Name (Legal Business Name): BRETT ROBERT LARSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3953 W STETSON AVE
HEMET CA
92545-9687
US

IV. Provider business mailing address

3953 W STETSON AVE
HEMET CA
92545-9687
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-4343
  • Fax: 951-765-6039
Mailing address:
  • Phone: 951-652-4343
  • Fax: 951-765-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: