Healthcare Provider Details

I. General information

NPI: 1326464488
Provider Name (Legal Business Name): LARKSPUR OPTOMETRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 LARKSPUR LN STE L
REDDING CA
96002-1043
US

IV. Provider business mailing address

2620 LARKSPUR LN STE L
REDDING CA
96002-1043
US

V. Phone/Fax

Practice location:
  • Phone: 530-223-4300
  • Fax: 530-222-8903
Mailing address:
  • Phone: 530-223-4300
  • Fax: 530-222-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7944TPG
License Number StateCA

VIII. Authorized Official

Name: NANCY COZETTE EKELUND
Title or Position: PRESIDENT
Credential: O.D.
Phone: 530-222-4300