1700263985 NPI number — MOOSE LAKE EYE CARE, LLC

Table of content: (NPI 1700263985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700263985 NPI number — MOOSE LAKE EYE CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOOSE LAKE EYE CARE, 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:
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:
1700263985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINCKLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55037-0728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-384-6361
Provider Business Mailing Address Fax Number:
320-384-6361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 LADY LUCK DR.
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
HINCKLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-384-6361
Provider Business Practice Location Address Fax Number:
320-384-6361
Provider Enumeration Date:
04/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NARAYAN
Authorized Official First Name:
SASHA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-485-8495

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  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: 1235188079 . This is a "PROVIDER NPI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1411674742 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1760558399 . This is a "PROVIDER NPI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1275582421 . This is a "PROVIDER NPI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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