Basic Information
| Provider Information | |||||||||
| NPI: | 1306452131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WORTHINGTON EYE CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 10TH ST | ||||||||
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| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561872767 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 702 10TH ST | ||||||||
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| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561872767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073765535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6057315640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.