Healthcare Provider Details

I. General information

NPI: 1063457943
Provider Name (Legal Business Name): ELK RIVER EYE CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19022 FREEPORT AVE NW SUITE H
ELK RIVER MN
55330-4767
US

IV. Provider business mailing address

19022 FREEPORT AVE NW SUITE H
ELK RIVER MN
55330-4767
US

V. Phone/Fax

Practice location:
  • Phone: 763-441-1055
  • Fax: 763-441-7024
Mailing address:
  • Phone: 763-441-1055
  • Fax: 763-441-7024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY MARK HOFFARD
Title or Position: PRESIDENT
Credential: O.D.
Phone: 763-441-1055