Healthcare Provider Details

I. General information

NPI: 1255819140
Provider Name (Legal Business Name): VANDERLEI OPTOMETRIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SHRINER ST
VERMILLION SD
57069-1155
US

IV. Provider business mailing address

130 CATALINA AVE
VERMILLION SD
57069-3318
US

V. Phone/Fax

Practice location:
  • Phone: 605-624-2020
  • Fax: 605-624-7961
Mailing address:
  • Phone: 605-661-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number727
License Number StateSD

VIII. Authorized Official

Name: DR. CLARENCE JOSEPH VANDERLEI
Title or Position: OWNER
Credential: OD
Phone: 605-661-1145