Healthcare Provider Details

I. General information

NPI: 1467815357
Provider Name (Legal Business Name): MINNESOTA EYE CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1347 LARPENTEUR AVE W
FALCON HEIGHTS MN
55113-6302
US

IV. Provider business mailing address

9801 DUPONT AVE S SUITE 425
BLOOMINGTON MN
55431-3100
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-5800
  • Fax: 651-641-1702
Mailing address:
  • Phone: 952-888-5800
  • Fax: 952-567-6156

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 Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: CANDACE S SIMERSON
Title or Position: COO/PRESIDENT
Credential:
Phone: 952-888-5800