Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | IL |
NPI | 1023379773 |
---|---|
Provider Name | Mr. Dylen Adair Larsen |
First Address | Belvidere, IL 61008 |
Second Address | Belvidere, IL 61008 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2012 |
Last Update Date | 30/05/2012 |