Healthcare Provider Details

I. General information

NPI: 1306837117
Provider Name (Legal Business Name): LARKSPUR LANDING OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/22/2020
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: 415-925-9091
  • Fax: 415-925-9092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number10121T
License Number StateCA

VIII. Authorized Official

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