Healthcare Provider Details

I. General information

NPI: 1982937827
Provider Name (Legal Business Name): KEITH LARSON NEUROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 NORTHWAY DR SUITE 202
SAINT CLOUD MN
56303-1261
US

IV. Provider business mailing address

1511 NORTHWAY DR SUITE 202
SAINT CLOUD MN
56303-1261
US

V. Phone/Fax

Practice location:
  • Phone: 320-217-8880
  • Fax: 320-253-1822
Mailing address:
  • Phone: 320-217-8880
  • Fax: 320-253-1822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number22693
License Number StateMN

VIII. Authorized Official

Name: DR. KEITH DARRYL LARSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 320-217-8880