Healthcare Provider Details

I. General information

NPI: 1467800664
Provider Name (Legal Business Name): PHAM-VANG OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7074 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-1370
US

IV. Provider business mailing address

7074 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-1370
US

V. Phone/Fax

Practice location:
  • Phone: 763-639-0103
  • Fax:
Mailing address:
  • Phone: 763-639-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3056
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number3056
License Number StateMN

VIII. Authorized Official

Name: DR. SANDY PHAM-VANG
Title or Position: CEO
Credential: OD
Phone: 763-316-4193