Provider Information for 1053812461
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KALEB ORVILLE LARSON MS
Other Names:Other Name:MARTY ORVILLE LARSON MSSex: Male
NPI: 1053812461
Last Updated: 2024-09-23
Certification Date: 2024-09-23
Certification Date: 2024-09-23
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1053812461 | ||||||||
| Enumeration Date | 2018-02-22 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | GIBAULT CARE INC. 6401 S. US HWY 41 TERRE HAUTE, IN 47805-4749 United States Phone: 812-299-1156 | Fax:812-299-0118 | ||||||||
| Primary Practice Address | 6401 S. US HWY 41 TERRE HAUTE, IN 47805-4749 United States Phone: 812-299-1156 | Fax:812-299-0118 | ||||||||
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