MEDICARE: MAPLE GROVE VISION CLINIC, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366472342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE GROVE VISION CLINIC, P.A.

Provider Business Mailing Address
First Line	:	13645 GROVE DR
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-4405
Country	:	US
Telephone Number	:	763-420-8030
Fax Number	:	763-420-8342

Provider Business Practice Location Address
First Line	:	13645 GROVE DR
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-4405
Country	:	US
Telephone Number	:	763-420-8030
Fax Number	:	763-420-8342

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	LINDA M THIEL
Credential	:
Telephone Number	:	763-420-8030

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	08/31/2009

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