Basic Information
| Provider Information | |||||||||
| NPI: | 1760740567 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MARSHALL | ||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP OPTOMETRY MARSHALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075329661 | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075325143 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2012 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILLAIMS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | V.P. OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5075379150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.