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General NPI Number Information
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NPI Number | 1811466212
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Entity Type | Organization
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Legal Business Name | LARS VAN ETTEN MD LLC
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Dates
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Enumeration Date | 11/15/2018
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Last Update Date | 11/15/2018
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Provider Practice Location Address
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Address Line | 25 MONTEBELLO RD
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City | PUEBLO
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State | CO
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Zip | 81001-1236
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Country | US
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Telephone | 719-544-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 334 GRACE AVE
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City | PUEBLO
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State | CO
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Zip | 81004-1032
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Country | US
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Telephone | 719-242-5811
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LARS VAN ETTEN
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Credential | MD
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Telephone | 719-242-5811
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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