=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003957127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARSON EYECARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 06/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 534 S DUFF AVE
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-956-3553
-----------------------------------------------------
Fax | 515-956-3555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3603 547TH AVE
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50010-9310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JULIE ANN LARSON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 515-233-0223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1985
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------