Healthcare Provider Details

I. General information

NPI: 1649327693
Provider Name (Legal Business Name): VISION OPTICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 NW 4TH ST
GRAND RAPIDS MN
55744-2582
US

IV. Provider business mailing address

426 NW 4TH ST
GRAND RAPIDS MN
55744-2582
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-1775
  • Fax: 218-326-3745
Mailing address:
  • Phone: 218-326-1775
  • Fax: 218-326-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2349
License Number StateMN

VIII. Authorized Official

Name: PAUL LEE DUBBELS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 218-326-1775