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General NPI Number Information
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NPI Number | 1174929160
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Entity Type | Organization
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Legal Business Name | VANDESTEEG & LARSON OPTOMETRIC CLINIC, PA
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Dates
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Enumeration Date | 11/18/2014
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Last Update Date | 07/16/2025
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Provider Practice Location Address
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Address Line | 24 1ST ST SE
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City | GLENWOOD
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State | MN
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Zip | 56334-1619
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Country | US
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Telephone | 320-634-4516
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Fax | 320-634-4520
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Provider Business Mailing Address
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Address Line | 24 1ST STREET SE
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City | GLENWOOD
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State | MN
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Zip | 56334
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Country | US
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Telephone | 320-634-4516
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Fax | 320-634-4520
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Authorized Official
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Title or Position | OWNER
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Name | DR. JONATHAN D LARSON
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Credential | OD
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Telephone | 320-634-4516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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