Healthcare Provider Details

I. General information

NPI: 1932272473
Provider Name (Legal Business Name): LITCHFIELD EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N SIBLEY AVE
LITCHFIELD MN
55355-1765
US

IV. Provider business mailing address

715 N SIBLEY AVE
LITCHFIELD MN
55355-1765
US

V. Phone/Fax

Practice location:
  • Phone: 320-693-3100
  • Fax: 320-693-2312
Mailing address:
  • Phone: 320-693-3100
  • Fax: 320-693-2312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1586
License Number StateMN

VIII. Authorized Official

Name: TERRANCE TANCABEL
Title or Position: OPTOMETRY
Credential: OD
Phone: 320-693-3100