1760655740 NPI number — MINNESOTA EYECARE NETWORK, INC

Table of content: (NPI 1760655740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760655740 NPI number — MINNESOTA EYECARE NETWORK, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA EYECARE NETWORK, 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:
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:
1760655740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
652 JEFFERSON STREET N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WADENA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56482-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-631-1456
Provider Business Mailing Address Fax Number:
281-631-3213

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 FRONT STREET S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARNESVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56514-0655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-354-2510
Provider Business Practice Location Address Fax Number:
218-354-2510
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NEITZKE
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-346-3310

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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