Healthcare Provider Details

I. General information

NPI: 1861656332
Provider Name (Legal Business Name): CLINT LARSEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 S FASHION BLVD STE 120
MURRAY UT
84107-8115
US

IV. Provider business mailing address

837 E. CEDAR ST SUITE 100
SOUTH BEND IN
46617
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-1391
  • Fax:
Mailing address:
  • Phone: 574-237-7338
  • Fax: 574-237-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number41000220
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: