1780671321 NPI number — FAMILY EYE CLINIC AND CONTACT LENS CENTER

Table of content: (NPI 1780671321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780671321 NPI number — FAMILY EYE CLINIC AND CONTACT LENS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY EYE CLINIC AND CONTACT LENS CENTER
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:
Provider Other Organization Name Type Code:
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:
1780671321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 WAYZATA BLVD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYZATA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55391-1963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-934-6926
Provider Business Mailing Address Fax Number:
952-934-6926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16550 W 78TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55346-4316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-934-6926
Provider Business Practice Location Address Fax Number:
952-473-9880
Provider Enumeration Date:
09/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REESE
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
RECEPTIONIST
Authorized Official Telephone Number:
952-934-6926

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01012099 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 16226FA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6768628-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CF8810 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".