Healthcare Provider Details

I. General information

NPI: 1053729152
Provider Name (Legal Business Name): BRADLY KENDALL LARSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2014
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8889 JEWELLA AVE STE C
SHREVEPORT LA
71118-2138
US

IV. Provider business mailing address

8889 JEWELLA AVE STE C
SHREVEPORT LA
71118-2138
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-5227
  • Fax: 381-686-5283
Mailing address:
  • Phone: 318-686-5227
  • Fax: 381-686-5283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1775-709T
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: