MEDICARE: ACKERMANN TOTAL EYE CARE 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	2672	MN

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
2	80G68AC	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1760511398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACKERMANN TOTAL EYE CARE INC

Provider Business Mailing Address
First Line	:	117 W CENTER ST
Second Line	:
City	:	LAKE CITY
State	:	MN
Zip	:	55041-1635
Country	:	US
Telephone Number	:	651-345-3039
Fax Number	:	651-345-3506

Provider Business Practice Location Address
First Line	:	117 W CENTER ST
Second Line	:
City	:	LAKE CITY
State	:	MN
Zip	:	55041-1635
Country	:	US
Telephone Number	:	651-345-3039
Fax Number	:	651-345-3506

Authorized Official
Title or Position	:	OPTOMETRIST OWNER
Name	:	MICHAEL DAVID ACKERMANN
Credential	:	OD
Telephone Number	:	651-345-3039

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	04/23/2008

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