1477624971 NPI number — EYE FASHIONS OPTICAL SHOPPE INC

Table of content: (NPI 1477624971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477624971 NPI number — EYE FASHIONS OPTICAL SHOPPE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE FASHIONS OPTICAL SHOPPE 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:
1477624971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 NW 1ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-326-0358
Provider Business Mailing Address Fax Number:
218-326-0566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 NW 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-326-0358
Provider Business Practice Location Address Fax Number:
218-326-0358
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHLAUDERAFF
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER OPTOMETRIST
Authorized Official Telephone Number:
218-326-0358

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2415 , 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: 1008835 . This is a "COPORATE BENEFIT SERV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4C427EY . This is a "BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4C427EY . This is a "MINN CARE BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: U33589 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 593932000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: U33589 . This is a "FIRSTPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: U33589 . This is a "FIRSTPLANBLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2200897 . This is a "MEDICA GR EX" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C838SC . This is a "BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C838SC . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 974251008835 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C837EY . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C837EY . This is a "BLUE PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 974251008835 . This is a "CBSA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP29720 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com