1205152618 NPI number — MINNESOTA EYE LASER & SURGERY CENTERS, LLC

Table of content: (NPI 1205152618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205152618 NPI number — MINNESOTA EYE LASER & SURGERY CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA EYE LASER & SURGERY CENTERS, LLC
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:
MINNESOTA EYE LASER & SURGERY CENTERS
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:
1205152618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9801 DUPONT AVE S
Provider Second Line Business Mailing Address:
SUITE 425
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-3100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-888-5800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11091 ULYSSES STREET NE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55434-4237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-888-5800
Provider Business Practice Location Address Fax Number:
952-567-6156
Provider Enumeration Date:
04/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BAZHAW
Authorized Official First Name:
CLIFTON
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP REVENUE CYCLE
Authorized Official Telephone Number:
469-270-6658

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24D2007008 . This is a "CLIA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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