1821366683 NPI number — STAPLES EYE CLINIC PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821366683 NPI number — STAPLES EYE CLINIC PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAPLES EYE CLINIC PSC
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:
1821366683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922 US 10 EAST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAPLES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56479-2428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-894-1331
Provider Business Mailing Address Fax Number:
218-895-1332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922 US 10 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAPLES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-894-1331
Provider Business Practice Location Address Fax Number:
218-895-1332
Provider Enumeration Date:
12/08/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOKKEN
Authorized Official First Name:
SETH
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-894-1331

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3172 , 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: 2334531 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".