Healthcare Provider Details

I. General information

NPI: 1699876417
Provider Name (Legal Business Name): LESLIE R MASCIARELLI KISCH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE R MASCIARELLI OD

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 WASHINGTON AVE OPTICAL EYEDEAS
DETROIT LAKES MN
56501
US

IV. Provider business mailing address

706 12TH ST SE
BARNESVILLE MN
56514-3960
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-8021
  • Fax: 218-846-9552
Mailing address:
  • Phone: 218-354-7065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2319
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number490
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: