1487706073 NPI number — EDA, INC

Table of content: (NPI 1487706073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487706073 NPI number — EDA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDA, INC
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:
PEARLE VISION
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:
1487706073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5515 XERXES AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN CENTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55430-2856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-560-1636
Provider Business Mailing Address Fax Number:
763-560-4101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5515 XERXES AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55430-2856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-560-1636
Provider Business Practice Location Address Fax Number:
763-560-4101
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
763-560-1636

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  1068294 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720056641 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 298N0PE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: PE1512552 . This is a "CLARITY VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21-20195 . This is a "MEDICA-UHC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2120195 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 781138100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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