| Organization Name: | VANDESTEEG & LARSON OPTOMETRIC CLINIC, PA |
| NPI Number: | 1174929160 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | STEPHEN M LARSON (OWNER) |
| Mailing Address: | 24 1st St Se Glenwood |
| State: | MN US |
| Postal Code: | 563341619 |
| Phone Number: | 3206344516 |
| Fax Number: | 3206344520 |
| NPI Enumeration Date: | 11/18/2014 |
| NPI Last Update Date: | 12/05/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |