Healthcare Provider Details

I. General information

NPI: 1902234602
Provider Name (Legal Business Name): COLETTE IRENE LARSEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11005 PINES BLVD STE 510
PEMBROKE PINES FL
33026-5217
US

IV. Provider business mailing address

2259 NOVA VILLAGE DR
DAVIE FL
33317-7032
US

V. Phone/Fax

Practice location:
  • Phone: 954-248-5010
  • Fax:
Mailing address:
  • Phone: 908-892-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4837
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: