Provider Demographics
NPI:1326464488
Name:LARKSPUR OPTOMETRY, INC.
Entity Type:Organization
Organization Name:LARKSPUR OPTOMETRY, INC.
Other - Org Name:NANCY EKELUND OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:COZETTE
Authorized Official - Last Name:EKELUND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-222-4300
Mailing Address - Street 1:2620 LARKSPUR LN STE L
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1043
Mailing Address - Country:US
Mailing Address - Phone:530-223-4300
Mailing Address - Fax:530-222-8903
Practice Address - Street 1:2620 LARKSPUR LN STE L
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1043
Practice Address - Country:US
Practice Address - Phone:530-223-4300
Practice Address - Fax:530-222-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7944TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0079440Medicaid
CA5198620001Medicare NSC
CAU09122Medicare UPIN
CASD0079440Medicaid