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General NPI Number Information
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NPI Number | 1902086416
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Entity Type | Individual
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Provider Name | TOMMY CLYDE LARISON D.C.
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Gender | Male
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Dates
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Enumeration Date | 11/13/2007
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Last Update Date | 03/04/2019
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Provider Practice Location Address
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Address Line | 3311 CANDELARIA RD NE STE K
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City | ALBUQUERQUE
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State | NM
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Zip | 87107-1952
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Country | US
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Telephone | 505-300-6390
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Fax | 866-373-3607
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Provider Business Mailing Address
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Address Line | 216 SANGRE DE CRISTO
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City | CEDAR CREST
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State | NM
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Zip | 87008-9525
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Country | US
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Telephone | 505-300-6390
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1714
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License Number State | NM
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