Healthcare Provider Details

I. General information

NPI: 1932268257
Provider Name (Legal Business Name): LE SUEUR EYECARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST S STE 103
LE SUEUR MN
56058-7503
US

IV. Provider business mailing address

101 MAIN ST S STE 103105
LE SUEUR MN
56058-7502
US

V. Phone/Fax

Practice location:
  • Phone: 507-665-3366
  • Fax: 507-665-3990
Mailing address:
  • Phone: 507-665-3366
  • Fax: 507-665-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ZACHARY BLAKE DIRKS
Title or Position: PARTNER
Credential: OD
Phone: 507-469-9715