Provider Demographics
NPI:1184992364
Name:OSGOOD EYECARE PROFESSIONALS, LLC
Entity type:Organization
Organization Name:OSGOOD EYECARE PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-304-1027
Mailing Address - Street 1:4622 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4394
Mailing Address - Country:US
Mailing Address - Phone:701-364-2909
Mailing Address - Fax:701-364-9346
Practice Address - Street 1:4622 40TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4394
Practice Address - Country:US
Practice Address - Phone:701-364-2909
Practice Address - Fax:701-364-9346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty