1255417002 NPI number — NORTHWEST EYE CLINIC, LLC

Table of content: (NPI 1255417002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255417002 NPI number — NORTHWEST EYE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST EYE CLINIC, 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:
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:
1255417002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8401 GOLDEN VALLEY RD STE 330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDEN VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55427-4488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-416-7629
Provider Business Mailing Address Fax Number:
763-383-4147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 39TH AVE NE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. ANTHONY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-416-7600
Provider Business Practice Location Address Fax Number:
763-416-7634
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETTENGILL
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING AND DATA MANAGEMENT
Authorized Official Telephone Number:
763-416-7629

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  360 , 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: 298616700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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