| Doctor Name: | MR. DYLEN ADAIR LARSEN |
| NPI Number: | 1023379773 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | ABOC |
| License Number: | |
| Business Practice Address: | 521 South Street Suite 1 Belvidere, IL - 61008 |
| Business Phone Number: | 8155201303 |
| Business Fax Number: | 8159759327 |
| Mailing Address: | 521 South Street, Suite 1 BELVIDERE |
| State: | IL |
| Postal Code: | 61008 |
| Phone Number: | 8155201303 |
| Fax Number: | 8159759327 |
| NPI Enumeration Date: | 05/30/2012 |
| NPI Last Update Date: | 05/30/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |