MEDICARE: ELLEN LARSEN

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	152W00000X	Optometrist	OPT.007068	OH

General Provider Information

NPI Number	:	1992444772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN LARSEN

Provider Business Mailing Address
First Line	:	2314 TAYLOR PARK DR
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-8052
Country	:	US
Telephone Number	:	614-863-0071
Fax Number	:	614-856-0534

Provider Business Practice Location Address
First Line	:	2314 TAYLOR PARK DR
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-8052
Country	:	US
Telephone Number	:	614-863-0071
Fax Number	:	614-856-0534

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

Provider Enumeration Date	:	06/01/2022
Last Update Date	:	04/06/2025

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