Provider Demographics
NPI:1851496053
Name:VANDESTEEG & LARSON OPTOMETRIC CLINIC PA
Entity Type:Organization
Organization Name:VANDESTEEG & LARSON OPTOMETRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-352-2774
Mailing Address - Street 1:314 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:SAUK CENTRE
Mailing Address - State:MN
Mailing Address - Zip Code:56378-1349
Mailing Address - Country:US
Mailing Address - Phone:320-352-2774
Mailing Address - Fax:
Practice Address - Street 1:314 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378-1349
Practice Address - Country:US
Practice Address - Phone:320-352-2774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN156323802Medicaid
MNC07658Medicare ID - Type Unspecified
MNC07657Medicare ID - Type Unspecified
MN156323802Medicaid