1336352475 NPI number — MIDWEST VISION CENTERS INC

Table of content: (NPI 1336352475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336352475 NPI number — MIDWEST VISION CENTERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST VISION CENTERS INC
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:
1336352475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 456
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56302-0456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-466-5777
Provider Business Mailing Address Fax Number:
320-258-3136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 S 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55792-3247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-749-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
CARIN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
888-466-5777

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131376 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 185691 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 203947000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 041N7MI . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2100779 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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