Healthcare Provider Details

I. General information

NPI: 1174929160
Provider Name (Legal Business Name): VANDESTEEG & LARSON OPTOMETRIC CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 1ST ST SE
GLENWOOD MN
56334-1619
US

IV. Provider business mailing address

24 1ST STREET SE
GLENWOOD MN
56334
US

V. Phone/Fax

Practice location:
  • Phone: 320-634-4516
  • Fax: 320-634-4520
Mailing address:
  • Phone: 320-634-4516
  • Fax: 320-634-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN D LARSON
Title or Position: OWNER
Credential: OD
Phone: 320-634-4516