1720167273 NPI number — NICHOLAS VINCELLI OPTOMETRY, INC.

Table of content: (NPI 1720167273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720167273 NPI number — NICHOLAS VINCELLI OPTOMETRY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICHOLAS VINCELLI OPTOMETRY, 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:
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:
1720167273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2095 HARBOUR OAK DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWATONNA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55060-6614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-220-4849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1881 E MADISON AVE
Provider Second Line Business Practice Location Address:
WAL-MART VISION CENTER STORE #1473
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-6200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-388-9805
Provider Business Practice Location Address Fax Number:
507-388-9812
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VINCELLI
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
CLINTON
Authorized Official Title or Position:
PRESIDENT/OPTOMETRIST
Authorized Official Telephone Number:
773-220-4849

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3035 , 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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