=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740352392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN ALBRIGHT LARSON P.T., O.C.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1105 E FOSTER RD STE B
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93455-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-934-0663
-----------------------------------------------------
Fax | 805-934-0663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 247 SANTA FE AVE
-----------------------------------------------------
City | PISMO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93449-1948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT 21537
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------