Provider Demographics
NPI:1316152929
Name:LARC ENTERPRISES
Entity type:Organization
Organization Name:LARC ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:SANGESLAND
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISPENSER
Authorized Official - Phone:315-255-2279
Mailing Address - Street 1:217 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1447
Mailing Address - Country:US
Mailing Address - Phone:315-255-2279
Mailing Address - Fax:315-255-1595
Practice Address - Street 1:217 GRANT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1447
Practice Address - Country:US
Practice Address - Phone:315-255-2279
Practice Address - Fax:315-255-1595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5203-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01668304Medicaid