MEDICARE: NICHOLAS VINCELLI OPTOMETRY, 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
1	152W00000X	Optometrist	3035	MN

General Provider Information

NPI Number	:	1720167273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICHOLAS VINCELLI OPTOMETRY, INC.

Provider Business Mailing Address
First Line	:	2095 HARBOUR OAK DR SE
Second Line	:
City	:	OWATONNA
State	:	MN
Zip	:	55060-6614
Country	:	US
Telephone Number	:	773-220-4849
Fax Number	:

Provider Business Practice Location Address
First Line	:	1881 E MADISON AVE
Second Line	:	WAL-MART VISION CENTER STORE #1473
City	:	MANKATO
State	:	MN
Zip	:	56001-6200
Country	:	US
Telephone Number	:	507-388-9805
Fax Number	:	507-388-9812

Authorized Official
Title or Position	:	PRESIDENT/OPTOMETRIST
Name	:	DR. NICHOLAS CLINTON VINCELLI
Credential	:	O.D.
Telephone Number	:	773-220-4849

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	05/11/2009

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