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General NPI Number Information
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NPI Number | 1982937827
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Entity Type | Organization
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Legal Business Name | KEITH LARSON NEUROLOGY PLLC
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Dates
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Enumeration Date | 09/10/2009
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Last Update Date | 09/10/2009
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Provider Practice Location Address
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Address Line | 1511 NORTHWAY DR SUITE 202
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City | SAINT CLOUD
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State | MN
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Zip | 56303-1261
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Country | US
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Telephone | 320-217-8880
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Fax | 320-253-1822
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Provider Business Mailing Address
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Address Line | 1511 NORTHWAY DR SUITE 202
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City | SAINT CLOUD
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State | MN
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Zip | 56303-1261
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Country | US
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Telephone | 320-217-8880
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Fax | 320-253-1822
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEITH DARRYL LARSON
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Credential | M.D.
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Telephone | 320-217-8880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 22693
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License Number State | MN
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