1689870156 NPI number — NORTH SUBURBAN EYE SPECIALISTS, LLP

Table of content: (NPI 1689870156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689870156 NPI number — NORTH SUBURBAN EYE SPECIALISTS, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH SUBURBAN EYE SPECIALISTS, LLP
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:
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NPI Number Information

NPI Number:
1689870156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11855 ULYSSES ST.
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-421-7420
Provider Business Mailing Address Fax Number:
763-421-0730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3790 COON RAPIDS BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-421-7420
Provider Business Practice Location Address Fax Number:
763-421-0730
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JORGENSEN
Authorized Official First Name:
DELTA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
763-421-7420

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , 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)





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