Healthcare Provider Details

I. General information

NPI: 1841319852
Provider Name (Legal Business Name): RUTH LARSON CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL SUITE 235
LAFAYETTE IN
47905-5760
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-5065
  • Fax: 765-446-5170
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-446-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number031728
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: