Healthcare Provider Details

I. General information

NPI: 1174389167
Provider Name (Legal Business Name): ZENITH VISION DEVELOPMENT CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 MAPLE GROVE RD
DULUTH MN
55811-1864
US

IV. Provider business mailing address

2522 MAPLE GROVE RD
DULUTH MN
55811-1864
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-0685
  • Fax: 218-461-4885
Mailing address:
  • Phone: 218-249-0685
  • Fax: 218-461-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: RAEANN NORDWALL
Title or Position: OWNER
Credential: OD
Phone: 218-249-0685