Healthcare Provider Details

I. General information

NPI: 1801033691
Provider Name (Legal Business Name): LARKSPUR LANDING OPTOMETRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 LARKSPUR LANDING CIR
LARKSPUR CA
94939-1802
US

IV. Provider business mailing address

2005 LARKSPUR LANDING CIR
LARKSPUR CA
94939-1802
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-9091
  • Fax: 415-925-9092
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10226T
License Number StateCA

VIII. Authorized Official

Name: DR. EDWARD IAN HAACK
Title or Position: OWNER
Credential: O.D.
Phone: 415-925-9091