1164448627 NPI number — CROSSROADS OPTOMETRIC CLINIC, INC.

Table of content: (NPI 1164448627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164448627 NPI number — CROSSROADS OPTOMETRIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS OPTOMETRIC CLINIC, 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:
LAKESIDE FAMILY EYE CARE
Provider Other Organization Name Type Code:
3
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:
1164448627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16250 DULUTH AVE SE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRIOR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55372-2883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-447-2020
Provider Business Mailing Address Fax Number:
952-447-2322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16250 DULUTH AVE SE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRIOR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55372-2883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-447-2020
Provider Business Practice Location Address Fax Number:
952-447-2322
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON-CLAUSEN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
OWNER/OPTOMETRIST
Authorized Official Telephone Number:
952-447-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0001425 , 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: 92364 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2123989 . This is a "MEDICA DME" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3C258CR . This is a "BCBS DME" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4825 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 51154HI . This is a "BCBS-MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2223987 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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