1184606949 NPI number — RUNESTONE EYE CARE, INC.

Table of content: (NPI 1184606949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184606949 NPI number — RUNESTONE EYE CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUNESTONE EYE CARE, 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:
RUNESTONE EYE CARE
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:
1184606949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3015 HIGHWAY 29 S
Provider Second Line Business Mailing Address:
SUITE 4155
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56308-3486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-759-1130
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 HIGHWAY 29 S
Provider Second Line Business Practice Location Address:
SUITE 4155
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56308-3486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-759-1130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WYSOSKI
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
320-759-1130

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2383 , 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: 1024868 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 971325500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2200241 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 30701135 . This is a "PRIMEWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 66Q23RU . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 66Q26RU . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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