Basic Information
| Provider Information | |||||||||
| NPI: | 1396832606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAYO CLINIC HEALTH SYSTEM-ALBERT LEA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 404 W FOUNTAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073732384 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 404 W FOUNTAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073732384 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROCKETT | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHAIR ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 5074225678 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 330838 | MN | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.