Healthcare Provider Details

I. General information

NPI: 1477748085
Provider Name (Legal Business Name): LARRY JAMES SCHLAUDERAFF O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 NW 1ST AVE
GRAND RAPIDS MN
55744-2703
US

IV. Provider business mailing address

202 NW 1ST AVE
GRAND RAPIDS MN
55744-2703
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0358
  • Fax: 218-326-0566
Mailing address:
  • Phone: 218-326-0358
  • Fax: 218-326-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMN2415
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: