Provider Demographics
NPI:1154347060
Name:PEARCE, LARISA LILES (LDN RD)
Entity type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:LILES
Last Name:PEARCE
Suffix:
Gender:F
Credentials:LDN RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-475-8140
Mailing Address - Fax:
Practice Address - Street 1:1000 WALTERS ST
Practice Address - Street 2:LSU W O MOSS REGIONAL MEDICAL CENTER
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4699
Practice Address - Country:US
Practice Address - Phone:337-475-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL853413133V00000X
LA1772133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
4H494D127Medicare UPIN
LA5D127Medicare ID - Type Unspecified