1972528776 NPI number — MICKELSON EYE CLINIC, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972528776 NPI number — MICKELSON EYE CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICKELSON EYE CLINIC, PA
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:
1972528776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 LABREE AVE S
Provider Second Line Business Mailing Address:
PO BOX 521
Provider Business Mailing Address City Name:
THIEF RIVER FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56701-2819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-683-3937
Provider Business Mailing Address Fax Number:
218-683-4557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 LABREE AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THIEF RIVER FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56701-2819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-683-3937
Provider Business Practice Location Address Fax Number:
218-683-4557
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MICKELSON
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/ OPTOMETRIST
Authorized Official Telephone Number:
218-683-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1891 , 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: 1026440 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2201140 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 71973 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 140661 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 61B37MI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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