Provider Demographics
NPI:1174929160
Name:VANDESTEEG & LARSON OPTOMETRIC CLINIC, PA
Entity type:Organization
Organization Name:VANDESTEEG & LARSON OPTOMETRIC CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-634-4516
Mailing Address - Street 1:24 1ST STREET SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334
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?:Yes
Parent Organization LBN:VANDESTEEG & LARSON OPTOMETRIC CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-18
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10000202944Medicaid
MN496063700Medicaid
MN0693670001Medicare NSC