Provider Demographics
NPI:1669944104
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:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-732-2313
Mailing Address - Street 1:240 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347
Mailing Address - Country:US
Mailing Address - Phone:320-732-2313
Mailing Address - Fax:320-533-3147
Practice Address - Street 1:240 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347
Practice Address - Country:US
Practice Address - Phone:320-732-2313
Practice Address - Fax:320-533-3147
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANDESTEEG & LARSON OPTOMETRIC CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty