1649348681 NPI number — EYE KLINIC INC

Table of content: (NPI 1649348681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649348681 NPI number — EYE KLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE KLINIC 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:
1649348681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4620 OAK GROVE PKWY N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55443-4062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-315-0909
Provider Business Mailing Address Fax Number:
763-315-0203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4620 OAK GROVE PKWY N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55443-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-315-0909
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KO
Authorized Official First Name:
JOSAN
Authorized Official Middle Name:
W. T.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
763-315-0909

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  MN2869 , 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: 26833 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 19981 . This is a "NVA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 822081600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21-00588 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MN02869 . This is a "VBA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 35135 . This is a "AVESIS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 958S7EY . This is a "BCBSM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 191361040082 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9529921700 . This is a "PATIENT CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: J52607 . This is a "DAVIS VSION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 181414 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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