1831263060 NPI number — SARA MABIE OD PA

Table of content: (NPI 1831263060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831263060 NPI number — SARA MABIE OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SARA MABIE OD PA
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:
1831263060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1189 GENEVA AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55128-5746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-702-2504
Provider Business Mailing Address Fax Number:
651-731-7905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1189 GENEVA AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55128-5746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-702-2504
Provider Business Practice Location Address Fax Number:
651-702-2504
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MABIE
Authorized Official First Name:
SARA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DOCTOR OF OPTOMETRY
Authorized Official Telephone Number:
651-436-3763

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2593 , 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: 2201213 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 39G01TA . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 637371026225 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 964223 . This is a "COLE MANAGED VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 637371016544 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 718317800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84615 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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