1235282633 NPI number — OAKDALE OPTICAL

Table of content: (NPI 1235282633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235282633 NPI number — OAKDALE OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKDALE OPTICAL
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:
1235282633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7013 10TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55128-5938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-738-8040
Provider Business Mailing Address Fax Number:
651-714-0759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7013 10TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55128-5938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-738-8040
Provider Business Practice Location Address Fax Number:
651-714-0759
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELVERUM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
651-738-8040

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  1460 , 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: 56097EL . This is a "BCBS SITE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 86629EL . This is a "BCBS PROVIDER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 101869 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 106141 . This is a "UCARE HARDWARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1C741OA . This is a "BCBS DISP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2222625 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2113780 . This is a "MEDICA DISP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 106141 . This is a "PREFERRED ONE GROUP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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