Basic Information
| Provider Information | |||||||||
| NPI: | 1083693220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOULDEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71827 PHILLIP DR | ||||||||
| Address2: | |||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560074251 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 404 W FOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073732384 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2938 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 602616800 | 05 | MN | MEDICAID |