=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740129642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARSON DIETETICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2026
-----------------------------------------------------
Last Update Date | 03/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 STONEYBROOK LN
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04539-3050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-914-3215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 STONEYBROOK LN
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04539-3050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-914-3215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. PHILIP ROBERT LARSON
-----------------------------------------------------
Credential | RDN
-----------------------------------------------------
Telephone | 918-914-3215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------