Provider Demographics
NPI:1205193554
Name:VANCE THOMPSON VISION CLINIC PROF LLC
Entity Type:Organization
Organization Name:VANCE THOMPSON VISION CLINIC PROF LLC
Other - Org Name:VANCE THOMPSON VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PALMER
Authorized Official - Last Name:BERDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-361-3937
Mailing Address - Street 1:3101 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-3162
Mailing Address - Country:US
Mailing Address - Phone:605-361-3937
Mailing Address - Fax:605-371-7199
Practice Address - Street 1:3101 W 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-3162
Practice Address - Country:US
Practice Address - Phone:605-361-3937
Practice Address - Fax:605-371-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty