1326133497 NPI number — THEOBALD FAMILY EYE CARE, LLP

Table of content: DR. JOHN ORSON WIRTHLIN DDS (NPI 1144506353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326133497 NPI number — THEOBALD FAMILY EYE CARE, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THEOBALD FAMILY EYE CARE, LLP
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:
6
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:
1326133497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3308 W ARROWHEAD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-727-6400
Provider Business Mailing Address Fax Number:
218-464-4277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55807-2548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-624-2095
Provider Business Practice Location Address Fax Number:
218-624-9545
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THEOBALD
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PARTNER
Authorized Official Telephone Number:
218-624-2095

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: CB6890 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6C246TH . This is a "BCBS & FIRST PLAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 402964000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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