1104855287 NPI number — EYECARE CENTERS OF AITKIN & MCGREGOR OPTOMETRISTS, PA

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 1104855287 NPI number — EYECARE CENTERS OF AITKIN & MCGREGOR OPTOMETRISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYECARE CENTERS OF AITKIN & MCGREGOR OPTOMETRISTS, 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:
1104855287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 MINNESOTA AVE N
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
AITKIN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-927-3213
Provider Business Mailing Address Fax Number:
218-927-2266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 MINNESOTA AVE. N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AITKIN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56431-1414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-927-3213
Provider Business Practice Location Address Fax Number:
218-927-2266
Provider Enumeration Date:
07/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KINZER
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER/PARTNER
Authorized Official Telephone Number:
218-927-3213

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2588 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 1998 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 601218300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".