Healthcare Provider Details

I. General information

NPI: 1972663383
Provider Name (Legal Business Name): ANDOVER OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13855 ROUND LAKE BLVD NW
ANDOVER MN
55304-3664
US

IV. Provider business mailing address

13855 ROUND LAKE BLVD NW
ANDOVER MN
55304-3664
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-0141
  • Fax: 763-421-0334
Mailing address:
  • Phone: 763-421-0141
  • Fax: 763-421-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number
License Number State

VIII. Authorized Official

Name: MS. LAINE SANGREN
Title or Position: VICE PRES
Credential:
Phone: 763-421-0141