MEDICARE: GREGORY LARSON MEDICAL TECHNOLOGIST

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	246Q00000X	Pathology Specialist/Technologist

General Provider Information

NPI Number	:	1295793875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY LARSON MEDICAL TECHNOLOGIST

Provider Business Mailing Address
First Line	:	11101 COYHWY 17
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501
Country	:	US
Telephone Number	:	218-846-9901
Fax Number	:

Provider Business Practice Location Address
First Line	:	40520 CO HWY 34
Second Line	:	WHITE EARTH HEALTH CENTER
City	:	OGEMA
State	:	MN
Zip	:	56569
Country	:	US
Telephone Number	:	218-983-4300
Fax Number	:	218-983-6217

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/08/2007

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