MEDICARE: ACADEMY CONTACT LENS CLINIC

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	2236	MN

General Provider Information

NPI Number	:	1639202559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADEMY CONTACT LENS CLINIC

Provider Business Mailing Address
First Line	:	2655 INNSBRUCK DR
Second Line	:	SUITE B
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9303
Country	:	US
Telephone Number	:	651-636-2020
Fax Number	:	651-633-5036

Provider Business Practice Location Address
First Line	:	2655 INNSBRUCK DR
Second Line	:	SUITE B
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9303
Country	:	US
Telephone Number	:	651-636-2020
Fax Number	:	651-633-5036

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN MARK CAVANAGH
Credential	:	O.D.
Telephone Number	:	651-636-2020

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	03/18/2009

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