MEDICARE: DR. CHAD LARSON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	38007103	IL

General Provider Information

NPI Number	:	1205921277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHAD LARSON D.C.

Provider Business Mailing Address
First Line	:	5214 N WESTERN AVE
Second Line	:	STE 102
City	:	CHICAGO
State	:	IL
Zip	:	60625-2589
Country	:	US
Telephone Number	:	773-784-1000
Fax Number	:	773-784-1398

Provider Business Practice Location Address
First Line	:	5214 N WESTERN AVE
Second Line	:	STE 102
City	:	CHICAGO
State	:	IL
Zip	:	60625-2589
Country	:	US
Telephone Number	:	773-784-1000
Fax Number	:	773-784-1398

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/17/2010

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