Basic Information
| Provider Information | |||||||||
| NPI: | 1780161539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERREAULT | ||||||||
| FirstName: | STACY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 ISLEVIEW RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557449769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182595782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 915 COUNTY ROAD 42 W STE 2036 | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553064427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524355011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3587 | MN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.