Healthcare Provider Details

I. General information

NPI: 1972232502
Provider Name (Legal Business Name): CHI NA MOUA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 04/11/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7835 150TH ST W
APPLE VALLEY MN
55124-7181
US

IV. Provider business mailing address

6719 PINE ARBOR BLVD S
COTTAGE GROVE MN
55016-4698
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-9709
  • Fax:
Mailing address:
  • Phone: 651-757-5749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3791
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: