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NPI Code Detail

MEDICARE: MONTICELLO OPTICAL CENTER INC.

MEDICARE: MONTICELLO OPTICAL CENTER INC.
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
1152W00000XOptometrist

General Provider Information

NPI Number : 1629591490
Entity Type Code : Organization
Provider Name (Legal Business Name) : MONTICELLO OPTICAL CENTER INC.
Provider Business Mailing Address
First Line : 2655 INNSBRUCK DR STE B
Second Line :
City : NEW BRIGHTON
State : MN
Zip : 55112-9304
Country : US
Telephone Number : 651-636-2020
Fax Number :
Provider Business Practice Location Address
First Line : 261 E BROADWAY ST
Second Line :
City : MONTICELLO
State : MN
Zip : 55362-9317
Country : US
Telephone Number : 763-295-5292
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. JOHN MARK CAVANAGH
Credential : O.D.
Telephone Number : 651-636-2020
Provider Enumeration Date : 07/24/2017
Last Update Date : 07/24/2017

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Directions to “MONTICELLO OPTICAL CENTER INC. ” Practice Location

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