Healthcare Provider Details

I. General information

NPI: 1841298445
Provider Name (Legal Business Name): LARRY DONAVON MORRISON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date: 03/15/2006
Reactivation Date: 07/07/2006

III. Provider practice location address

785 S HIGHWAY 59
MAHNOMEN MN
56557-5007
US

IV. Provider business mailing address

785 SO HIGHWAY 59 P O BOX 339
MAHNOMEN MN
56557-5007
US

V. Phone/Fax

Practice location:
  • Phone: 218-936-2020
  • Fax: 218-935-5541
Mailing address:
  • Phone: 218-936-2020
  • Fax: 218-935-5541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1739
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: