MEDICARE: LARSON HEALTH PROVIDERS

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	207P00000X	Emergency Medicine Physician	G38734	CA

General Provider Information

NPI Number	:	1740412774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARSON HEALTH PROVIDERS

Provider Business Mailing Address
First Line	:	419 N LARCHMONT BLVD
Second Line	:	STE 78
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	419 N LARCHMONT BLVD
Second Line	:	STE 78
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3013
Country	:	US
Telephone Number	:	323-307-1552
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JAMES M LARSON
Credential	:
Telephone Number	:	323-307-1552

Provider Enumeration Date	:	08/08/2009
Last Update Date	:	11/10/2009

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