1669565412 NPI number — WADENA EYE CLINIC LTD

Table of content: (NPI 1669565412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669565412 NPI number — WADENA EYE CLINIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WADENA EYE CLINIC LTD
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:
1669565412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/17/2007
NPI Reactivation Date:
01/14/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 SOUTHEAST FIRST STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WADENA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56482-1567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-631-2020
Provider Business Mailing Address Fax Number:
218-631-1892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 SOUTHEAST FIRST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADENA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56482-1567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-631-2020
Provider Business Practice Location Address Fax Number:
218-631-1892
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
218-631-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 57331 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5C053WA . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2116301 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 297717600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 999995765 . This is a "VSP-DR.TABBERT" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 83294MI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 999995764 . This is a "VSP-DR.MILLER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com