Provider Demographics
NPI:1922401694
Name:VANDESTEEG & LARSON OPTOMETRIC CLINIC PA
Entity Type:Organization
Organization Name:VANDESTEEG & LARSON OPTOMETRIC CLINIC PA
Other - Org Name:GLACIAL RIDGE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-634-4516
Mailing Address - Street 1:24 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1619
Mailing Address - Country:US
Mailing Address - Phone:320-634-4516
Mailing Address - Fax:320-634-4520
Practice Address - Street 1:24 1ST ST SE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1619
Practice Address - Country:US
Practice Address - Phone:320-634-4516
Practice Address - Fax:320-634-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1709152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty