1457563827 NPI number — MINNESOTA VISION OUTREACH, INC

Table of content: (NPI 1457563827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457563827 NPI number — MINNESOTA VISION OUTREACH, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA VISION OUTREACH, 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:
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:
1457563827
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9905 45TH AVENUE NORTH
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55422-3315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-595-8414
Provider Business Mailing Address Fax Number:
763-595-8438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9905 45TH AVENUE NORTH
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-595-8414
Provider Business Practice Location Address Fax Number:
763-595-8414
Provider Enumeration Date:
05/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOLFSON
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-585-8414

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1706 , 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: 2100002 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 23979 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3C780MI . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2115998 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 102877 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 096744100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19467WO . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2499537 . This is a "MHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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