1407943897 NPI number — NORTHERN MINNESOTA EYE CARE LLC

Table of content: (NPI 1407943897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407943897 NPI number — NORTHERN MINNESOTA EYE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN MINNESOTA EYE CARE LLC
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:
VISTA EYES
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:
1407943897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 22ND ST
Provider Second Line Business Mailing Address:
APT 301
Provider Business Mailing Address City Name:
CLOQUET
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55720-2876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-495-9669
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 S 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55792-3247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-495-9669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NARAYAN
Authorized Official First Name:
SASHA
Authorized Official Middle Name:
NIRANJALI
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-495-9669

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2979/2974 , 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: 25062 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 488P1VI . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 21-00779 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".