Healthcare Provider Details

I. General information

NPI: 1538053277
Provider Name (Legal Business Name): TRAVIS ADAM LARSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SHRINER ST
VERMILLION SD
57069-1155
US

IV. Provider business mailing address

11 SHRINER ST
VERMILLION SD
57069-1155
US

V. Phone/Fax

Practice location:
  • Phone: 605-624-2020
  • Fax: 605-624-7961
Mailing address:
  • Phone: 605-624-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number836
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: