Healthcare Provider Details

I. General information

NPI: 1578304556
Provider Name (Legal Business Name): JOSEPH D LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 STANLEY ST
NEW BRITAIN CT
06050-2439
US

IV. Provider business mailing address

23 PARK LN E
NEW MILFORD CT
06776-2528
US

V. Phone/Fax

Practice location:
  • Phone: 860-832-3086
  • Fax:
Mailing address:
  • Phone: 203-300-4037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: