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NPI Code Detail

MEDICARE: LAURA L LARSON O.D.

MEDICARE: LAURA L LARSON O.D.
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
1152W00000XOptometrist2592MN

General Provider Information

NPI Number : 1487715124
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAURA L LARSON O.D.
Provider Business Mailing Address
First Line : 6925 RUBY LN
Second Line :
City : CHANHASSEN
State : MN
Zip : 55317-7595
Country : US
Telephone Number : 952-474-3532
Fax Number :
Provider Business Practice Location Address
First Line : 8000 LAKELAND AVE N
Second Line :
City : BROOKLYN PARK
State : MN
Zip : 55445-2403
Country : US
Telephone Number : 763-425-4890
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/13/2006
Last Update Date : 07/08/2007

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