Healthcare Provider Details

I. General information

NPI: 1265876056
Provider Name (Legal Business Name): MARK WAYNE LARSON MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10093 SUNNY LN
OOLTEWAH TN
37363-8487
US

IV. Provider business mailing address

PO BOX 1505 10093 SUNNY LANE
COLLEGEDALE TN
37315-1505
US

V. Phone/Fax

Practice location:
  • Phone: 423-838-8906
  • Fax:
Mailing address:
  • Phone: 423-838-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9061
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: