1811036056 NPI number — DR. CANDACE CHRISTEN O.D.

Table of content: DR. CANDACE CHRISTEN O.D. (NPI 1811036056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811036056 NPI number — DR. CANDACE CHRISTEN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTEN
Provider First Name:
CANDACE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1811036056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 SANDY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55362-8968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-310-2203
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 SANDY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55362-8968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-310-2203
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2960 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 3269 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: TPOP48 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: TA2880 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 3498-35 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MN2960 . This is a "STATE LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-04250 . This is a "MEDICA, JCP LOCATION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2960 . This is a "LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 538K5CH . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-04249 . This is a "MEDICA, MACY'S LOCATION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 221006 . This is a "EYEMED" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: TPOP48 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3498-35 . This is a "LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 3498-35 . This is a "STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 560-131-200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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