Healthcare Provider Details

I. General information

NPI: 1760655740
Provider Name (Legal Business Name): MINNESOTA EYECARE NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 FRONT STREET S
BARNESVILLE MN
56514-0655
US

IV. Provider business mailing address

652 JEFFERSON STREET N
WADENA MN
56482-2307
US

V. Phone/Fax

Practice location:
  • Phone: 218-354-2510
  • Fax: 218-354-2510
Mailing address:
  • Phone: 218-631-1456
  • Fax: 281-631-3213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY C NEITZKE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 218-346-3310