Provider Demographics
NPI:1801033691
Name:LARKSPUR LANDING OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:LARKSPUR LANDING OPTOMETRIC CORPORATION
Other - Org Name:LARKSPUR LANDING OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:HAACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:415-925-9091
Mailing Address - Street 1:2005 LARKSPUR LANDING CIR
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 LARKSPUR LANDING CIR
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1802
Practice Address - Country:US
Practice Address - Phone:415-925-9091
Practice Address - Fax:415-925-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10226T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174516462OtherNPI
CA1972725760OtherNPI
CAU52666Medicare UPIN
CAU65869Medicare UPIN
CASD0103260Medicare PIN
CA1972725760OtherNPI
CASD0101210Medicare PIN