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General NPI Number Information
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NPI Number | 1720196421
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Entity Type | Individual
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Provider Name | LINDA RUSNOCK LARSEN O.D.
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Gender | Female
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 22250 PROVIDENCE DR SUITE 304
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City | SOUTHFIELD
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State | MI
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Zip | 48075-4825
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Country | US
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Telephone | 248-569-4366
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Fax | 248-569-4614
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Provider Business Mailing Address
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Address Line | 29562 POND RIDGE RD
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-3031
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Country | US
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Telephone | 248-737-3923
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901002714
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License Number State | MI
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