Healthcare Provider Details

I. General information

NPI: 1659635209
Provider Name (Legal Business Name): AMJ OPTOMETRIC SERVICES PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 03/27/2024
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 STAR ST STE 101
MANKATO MN
56001-4889
US

IV. Provider business mailing address

111 STAR ST STE 101
MANKATO MN
56001-4889
US

V. Phone/Fax

Practice location:
  • Phone: 507-387-6695
  • Fax: 507-668-0358
Mailing address:
  • Phone: 507-387-6695
  • Fax: 507-668-0358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3175
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateMN

VIII. Authorized Official

Name: ANGELA MICHELLE JOHNSON
Title or Position: CEO
Credential: OD
Phone: 507-387-6695