Healthcare Provider Details

I. General information

NPI: 1083106314
Provider Name (Legal Business Name): LAUREN ELISABETH BRUEHL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 05/23/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 BOTTINEAU BLVD
CRYSTAL MN
55429-3181
US

IV. Provider business mailing address

5730 BOTTINEAU BLVD
CRYSTAL MN
55429-3181
US

V. Phone/Fax

Practice location:
  • Phone: 763-537-3213
  • Fax:
Mailing address:
  • Phone: 763-537-3213
  • Fax: 763-537-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3554
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: