Provider Demographics
NPI:1225313661
Name:DAN SODERBERG OD LLC
Entity Type:Organization
Organization Name:DAN SODERBERG OD LLC
Other - Org Name:GROVE CITY OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SODERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:724-458-8533
Mailing Address - Street 1:808 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1114
Mailing Address - Country:US
Mailing Address - Phone:724-458-8533
Mailing Address - Fax:724-458-0911
Practice Address - Street 1:808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1114
Practice Address - Country:US
Practice Address - Phone:724-458-8533
Practice Address - Fax:724-458-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty