MEDICARE: DAVE SCOTT LARSON PT

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1265590566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVE SCOTT LARSON PT

Provider Business Mailing Address
First Line	:	9292 SUNRISE PARK DR
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-2479
Country	:	US
Telephone Number	:	801-572-6463
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 WAKARA WAY
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-587-7005
Fax Number	:

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	11/17/2021

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