Healthcare Provider Details

I. General information

NPI: 1407217367
Provider Name (Legal Business Name): LARISSA VADOS L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAINT JOHNS BLVD STE 101
MAPLEWOOD MN
55109
US

IV. Provider business mailing address

1600 SAINT JOHNS BLVD STE 101
MAPLEWOOD MN
55109-1190
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-5354
  • Fax:
Mailing address:
  • Phone: 651-232-5354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1785
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: