Basic Information
| Provider Information | |||||||||
| NPI: | 1053532929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED VISION CARE PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALLEY EYE CLINIC AND OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 223 1ST ST E STE 101 | ||||||||
| Address2: | |||||||||
| City: | JORDAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553521563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524922350 | ||||||||
| FaxNumber: | 9524926162 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 1ST ST E STE 101 | ||||||||
| Address2: | |||||||||
| City: | JORDAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553521563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524922350 | ||||||||
| FaxNumber: | 9524926162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUEHMANN | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST /CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9524922350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2848 | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 110122 | 01 | MN | HEALTH PARTNERS CLINIC ID | OTHER | 340K6VA | 01 | MN | BCBS OF MN CLINIC ID | OTHER | 480110500 | 05 | MN | MEDICAID |