Provider Demographics
NPI:1063139772
Name:LARSEN, CRAIG M (CPRC, CPRC-S)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:LARSEN
Suffix:
Gender:M
Credentials:CPRC, CPRC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4735
Mailing Address - Country:US
Mailing Address - Phone:208-402-6782
Mailing Address - Fax:
Practice Address - Street 1:304 W LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4735
Practice Address - Country:US
Practice Address - Phone:208-402-6782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11926175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist