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General NPI Number Information
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NPI Number | 1194806117
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Entity Type | Organization
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Legal Business Name | TARRA VANDER LEEST OD PC
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Dates
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Enumeration Date | 10/17/2006
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Last Update Date | 12/23/2023
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Provider Practice Location Address
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Address Line | 1306 18TH ST SUITE E
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City | SPIRIT LAKE
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State | IA
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Zip | 51360-1163
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Country | US
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Telephone | 712-336-4401
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Fax | 712-336-4403
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Provider Business Mailing Address
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Address Line | 3135 SUNNER AVE
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City | SPIRIT LAKE
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State | IA
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Zip | 51360-7678
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Country | US
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Telephone | 712-330-0276
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TARRA L VANDER LEEST
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Credential | O.D.
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Telephone | 712-330-0276
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 02288
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License Number State | IA
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