Healthcare Provider Details

I. General information

NPI: 1831506252
Provider Name (Legal Business Name): SAVAGE EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 CEDAR GROVE PKWY
EAGAN MN
55122-1403
US

IV. Provider business mailing address

5809 EGAN DR
SAVAGE MN
55378-4918
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-5661
  • Fax: 651-454-5669
Mailing address:
  • Phone: 952-226-2020
  • Fax: 952-226-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6350254
License Number StateMN

VIII. Authorized Official

Name: KRIS HAFFNER
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 651-454-5661