Provider Demographics
NPI:1053522888
Name:LARSON FOOT CLINIC, P.C.
Entity type:Organization
Organization Name:LARSON FOOT CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JENNINGS
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:402-391-0960
Mailing Address - Street 1:2821 S 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3046
Mailing Address - Country:US
Mailing Address - Phone:402-391-0960
Mailing Address - Fax:402-391-1463
Practice Address - Street 1:2821 S 87TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3046
Practice Address - Country:US
Practice Address - Phone:402-391-0960
Practice Address - Fax:402-391-1463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE157213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE4912550001Medicare NSC
NET71378Medicare UPIN
NE091202Medicare PIN