1306042817 NPI number — NORTH SUBURBAN OPTICAL

Table of content: (NPI 1306042817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306042817 NPI number — NORTH SUBURBAN OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH SUBURBAN OPTICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPTICAL STUDIOS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306042817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3777 COON RAPIDS BLVD NW # 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-421-8524
Provider Business Mailing Address Fax Number:
763-421-0730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11855 ULYSSES ST
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-421-7420
Provider Business Practice Location Address Fax Number:
763-421-0730
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOBANOFF
Authorized Official First Name:
MARK
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
763-421-7420

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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