Provider Demographics
NPI:1336449388
Name:LARRY E WAGGONER O D PROF CORP
Entity Type:Organization
Organization Name:LARRY E WAGGONER O D PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:760-379-3602
Mailing Address - Street 1:12134 MOUNT MESA RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9690
Mailing Address - Country:US
Mailing Address - Phone:760-379-3602
Mailing Address - Fax:760-379-2232
Practice Address - Street 1:12134 MOUNT MESA RD
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9690
Practice Address - Country:US
Practice Address - Phone:760-379-3602
Practice Address - Fax:760-379-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty