Healthcare Provider Details

I. General information

NPI: 1023615069
Provider Name (Legal Business Name): EAGAN EYE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12390 SHERBURNE AVE
BECKER MN
55308-9147
US

IV. Provider business mailing address

211 E BROADWAY
ALTON IL
62002-6220
US

V. Phone/Fax

Practice location:
  • Phone: 632-441-7007
  • Fax:
Mailing address:
  • Phone: 618-462-9818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN S. CHUDNER
Title or Position: PRESIDENT
Credential: OD
Phone: 972-370-5552