Healthcare Provider Details

I. General information

NPI: 1902138407
Provider Name (Legal Business Name): SANTALUZ LIMITED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 OAK ST
EXCELSIOR MN
55331-3030
US

IV. Provider business mailing address

143 OAK ST
EXCELSIOR MN
55331-3030
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-1701
  • Fax: 952-401-7908
Mailing address:
  • Phone: 952-401-1701
  • Fax: 952-401-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. JASON ERIC TRUCANO
Title or Position: OWNER
Credential:
Phone: 952-401-1701