1144343252 NPI number — SOUTHWEST EYE CARE

Table of content: (NPI 1144343252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144343252 NPI number — SOUTHWEST EYE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST EYE CARE
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:
1144343252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1464 WHITE OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHASKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55318-2525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-466-3937
Provider Business Mailing Address Fax Number:
952-466-3936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 GREELEY AVE N # 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENCOE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55336-2135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-864-2020
Provider Business Practice Location Address Fax Number:
320-864-6684
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NARUM
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
LEANN
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
952-466-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2627 , 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: 617518000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1881741213 . This is a "NPI AMY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1922004514 . This is a "GREGORY MACIK" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1104975762 . This is a "NPI CHAD DOCKTER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1770631889 . This is a "CHRISTOPHER FREED" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 650127300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 958906600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 683719100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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