Healthcare Provider Details

I. General information

NPI: 1528889193
Provider Name (Legal Business Name): SAMANTHA JO LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA JO ANDERSON

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 10TH AVE
MENOMINEE MI
49858-3058
US

IV. Provider business mailing address

1110 10TH AVE
MENOMINEE MI
49858-3058
US

V. Phone/Fax

Practice location:
  • Phone: 906-290-5000
  • Fax: 906-863-2408
Mailing address:
  • Phone: 906-290-5000
  • Fax: 906-863-2408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: