Healthcare Provider Details

I. General information

NPI: 1881096071
Provider Name (Legal Business Name): WILHELM C J LARSEN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 POTTER RD
WEST PALM BEACH FL
33405-3621
US

IV. Provider business mailing address

PO BOX 220688 3900 HARVERHILL ROAD NORTH
WEST PALM BEACH FL
33422-0688
US

V. Phone/Fax

Practice location:
  • Phone: 561-707-4161
  • Fax: 561-908-2604
Mailing address:
  • Phone: 561-707-4161
  • Fax: 561-791-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberME0027507
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberME0027507
License Number StateFL

VIII. Authorized Official

Name: DR. WILHELM CHARLES JOSEPH LARSEN
Title or Position: OWNER, PRESIDENT
Credential: MD
Phone: 561-707-4161