1568624195 NPI number — DR. JESSICA LOEHR OPTOMETRIST

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 1568624195 NPI number — DR. JESSICA LOEHR OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOEHR
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OPTOMETRIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUDOPLPH
Provider Other First Name:
JESSICA
Provider Other Middle Name:
LOEHR
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568624195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
952-443-2387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 E 78TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55420-1397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-854-2262
Provider Business Practice Location Address Fax Number:
952-854-5493
Provider Enumeration Date:
06/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3128 , 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: 398110100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410002988 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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