Basic Information
| Provider Information | |||||||||
| NPI: | 1215014378 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYEWEAR SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7450 FRANCE AVE S | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528328120 | ||||||||
| FaxNumber: | 9528328124 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 DEAN LAKES BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553792829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524455763 | ||||||||
| FaxNumber: | 9522333029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | MAYNE | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9528328100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 4699580 | MN | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 21-27952 | 01 | MN | MEDICA | OTHER | 51083CL | 01 | MN | BCBS | OTHER | 6944973-00 | 05 | MN | MEDICAID |