Healthcare Provider Details

I. General information

NPI: 1538023106
Provider Name (Legal Business Name): ALEXANDRA LARCOM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 GASTON ST
MEDFORD MA
02155-1220
US

IV. Provider business mailing address

42 GASTON ST
MEDFORD MA
02155-1220
US

V. Phone/Fax

Practice location:
  • Phone: 954-328-9287
  • Fax:
Mailing address:
  • Phone: 954-328-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN3049
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: