1366863862 NPI number — PATIENT CENTERED EYE CARE OF MINNESOTA LLC

Table of content: (NPI 1366863862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366863862 NPI number — PATIENT CENTERED EYE CARE OF MINNESOTA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATIENT CENTERED EYE CARE OF MINNESOTA 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:
1366863862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3109 W 50TH ST
Provider Second Line Business Mailing Address:
STE 124
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55410-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-488-3937
Provider Business Mailing Address Fax Number:
866-415-6805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3109 W 50TH ST
Provider Second Line Business Practice Location Address:
STE 124
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55410-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-488-3937
Provider Business Practice Location Address Fax Number:
866-415-6805
Provider Enumeration Date:
12/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ELAM
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
855-488-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3367 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 3367 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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