Provider Demographics
NPI:1255819140
Name:VANDERLEI OPTOMETRIC PC
Entity type:Organization
Organization Name:VANDERLEI OPTOMETRIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:VANDERLEI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-661-1145
Mailing Address - Street 1:130 CATALINA AVE
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-3318
Mailing Address - Country:US
Mailing Address - Phone:605-661-1145
Mailing Address - Fax:
Practice Address - Street 1:11 SHRINER ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-1155
Practice Address - Country:US
Practice Address - Phone:605-624-2020
Practice Address - Fax:605-624-7961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty