Basic Information
| Provider Information | |||||||||
| NPI: | 1003957127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LARSON EYECARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3603 547TH AVE | ||||||||
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| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500109310 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 534 S DUFF AVE | ||||||||
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| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159563553 | ||||||||
| FaxNumber: | 5159563555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | LARSON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5152330223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1985 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.