1316379647 NPI number — MINNESOTA EYE LASER & SURGERY CENTERS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316379647 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:
Provider Other Organization Name Type Code:
6
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:
1316379647
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:
SUTIE 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:
10709 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-5509
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:
08/09/2013

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)





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