Healthcare Provider Details

I. General information

NPI: 1649348681
Provider Name (Legal Business Name): EYE KLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 OAK GROVE PKWY N
BROOKLYN PARK MN
55443-4062
US

IV. Provider business mailing address

4620 OAK GROVE PKWY N
BROOKLYN PARK MN
55443-4062
US

V. Phone/Fax

Practice location:
  • Phone: 763-315-0909
  • Fax:
Mailing address:
  • Phone: 763-315-0909
  • Fax: 763-315-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberMN2869
License Number StateMN

VIII. Authorized Official

Name: JOSAN W. T. KO
Title or Position: CEO
Credential:
Phone: 763-315-0909