Healthcare Provider Details

I. General information

NPI: 1619703006
Provider Name (Legal Business Name): REGIONAL EYE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHASKA CREEK WAY STE 110
CHASKA MN
55318-2749
US

IV. Provider business mailing address

1200 CHASKA CREEK WAY STE 110
CHASKA MN
55318-2749
US

V. Phone/Fax

Practice location:
  • Phone: 952-466-3937
  • Fax: 952-466-3936
Mailing address:
  • Phone: 952-466-3937
  • Fax: 952-466-3936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: CLIFTON CHAD BAZHAW
Title or Position: CHIEF REVENUE OFFICER
Credential:
Phone: 469-270-6658