Healthcare Provider Details

I. General information

NPI: 1780163691
Provider Name (Legal Business Name): ALAYNA LARSEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11735 POINTE PL
ROSWELL GA
30076-4636
US

IV. Provider business mailing address

155 HOPEWELL GROVE DR
MILTON GA
30004-6989
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-4235
  • Fax: 954-262-3904
Mailing address:
  • Phone: 561-356-5619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPT003208
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: