Healthcare Provider Details

I. General information

NPI: 1669596821
Provider Name (Legal Business Name): LARRY CHAN LMT, CNMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 W COLORADO AVE
COLORADO SPRINGS CO
80905-1517
US

IV. Provider business mailing address

923 W COLORADO AVE
COLORADO SPRINGS CO
80905-1517
US

V. Phone/Fax

Practice location:
  • Phone: 719-432-8477
  • Fax: 719-227-0303
Mailing address:
  • Phone: 719-432-8477
  • Fax: 719-227-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1330
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: