Healthcare Provider Details

I. General information

NPI: 1629148614
Provider Name (Legal Business Name): ANNANDALE EYE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ELM ST E
ANNANDALE MN
55302
US

IV. Provider business mailing address

PO BOX 128
ANNANDALE MN
55302-0128
US

V. Phone/Fax

Practice location:
  • Phone: 320-274-3701
  • Fax: 320-274-3784
Mailing address:
  • Phone: 320-274-3701
  • Fax: 320-274-3784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1765
License Number StateMN

VIII. Authorized Official

Name: DR. TERRENCE LEE TANCABEL
Title or Position: OWNER
Credential: O.D.
Phone: 320-274-3701