1265647416 NPI number — PROGRESSIVE EYECARE ASSOCIATES

Table of content: (NPI 1265647416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265647416 NPI number — PROGRESSIVE EYECARE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE EYECARE ASSOCIATES
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:
1265647416
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:
1690 UNIVERSITY AVE WEST
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-645-3997
Provider Business Mailing Address Fax Number:
651-641-7207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14655 GALAXIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-645-3997
Provider Business Practice Location Address Fax Number:
651-641-7207
Provider Enumeration Date:
05/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
DIANNA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
651-645-3997

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  776 , 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: CS0820 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0461340002 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com