Healthcare Provider Details

I. General information

NPI: 1245012160
Provider Name (Legal Business Name): MR. LARRY DAVID LARGEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HARRIS SPRINGS RD
LAS VEGAS NV
89124-9215
US

IV. Provider business mailing address

8152 LEGER DR
LAS VEGAS NV
89145-4742
US

V. Phone/Fax

Practice location:
  • Phone: 702-872-5382
  • Fax:
Mailing address:
  • Phone: 702-872-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number07589-1
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: