Healthcare Provider Details

I. General information

NPI: 1548383326
Provider Name (Legal Business Name): LARSEN CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 N WABASH ST
PERU IN
46970-2224
US

IV. Provider business mailing address

7 N WABASH ST
PERU IN
46970-2224
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-1127
  • Fax: 765-472-5228
Mailing address:
  • Phone: 765-472-1127
  • Fax: 765-472-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001019A
License Number StateIN

VIII. Authorized Official

Name: DR. MARK WILLIAM LARSEN
Title or Position: PRESIDENT
Credential: DOCTOR OF CHIROPRACT
Phone: 765-472-1127