Healthcare Provider Details

I. General information

NPI: 1013229129
Provider Name (Legal Business Name): CRAIG ALAN LARSON LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W CHARLESTON BLVD STE 170
LAS VEGAS NV
89102-1682
US

IV. Provider business mailing address

304 HORSE POINTE AVE
NORTH LAS VEGAS NV
89084-1224
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-4673
  • Fax: 702-453-2673
Mailing address:
  • Phone: 702-236-4484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number232
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: