1972657658 NPI number — ST PETER EYECARE CENTER, INC

Table of content: (NPI 1972657658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972657658 NPI number — ST PETER EYECARE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST PETER EYECARE CENTER, 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:
LECENTER EYECARE
Provider Other Organization Name Type Code:
5
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:
1972657658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 SUNRISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PETER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56082-1352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-931-6436
Provider Business Mailing Address Fax Number:
507-934-9625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 E MINNESOTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LE CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56057-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-357-6665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIRKS
Authorized Official First Name:
BLAKE
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
507-931-6436

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2076 , 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: 0322460001 . This is a "DMERC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 15568 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 33077DI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 44977TH . This is a "BLUEPLUS EYEWEAR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114338 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2200871 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 706140400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: C06707 . This is a "MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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