Healthcare Provider Details

I. General information

NPI: 1073706511
Provider Name (Legal Business Name): LARSON CHIROPRACTIC,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2007
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 MULLINS COLONY DR
EVANS GA
30809-0579
US

IV. Provider business mailing address

676 MULLINS COLONY DR
EVANS GA
30809-0579
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-8550
  • Fax: 706-210-7105
Mailing address:
  • Phone: 706-210-8550
  • Fax: 706-210-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberCHIRO07425
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO07425
License Number StateGA

VIII. Authorized Official

Name: DR. ERIC JOHN LARSON
Title or Position: OWNER
Credential: DC
Phone: 706-210-8550