Healthcare Provider Details

I. General information

NPI: 1174052211
Provider Name (Legal Business Name): TOMMY LARSON CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2017
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 S VILLAGE SQ
CANTON GA
30115-1861
US

IV. Provider business mailing address

266 S VILLAGE SQ
CANTON GA
30115-1861
US

V. Phone/Fax

Practice location:
  • Phone: 770-851-3123
  • Fax:
Mailing address:
  • Phone: 770-851-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: