Healthcare Provider Details

I. General information

NPI: 1760636286
Provider Name (Legal Business Name): NICOLLET VISION CARE OPTOMETRISTS P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 HENNEPIN AVE S
MINNEAPOLIS MN
55408-2619
US

IV. Provider business mailing address

3142 HENNEPIN AVE S
MINNEAPOLIS MN
55408-2619
US

V. Phone/Fax

Practice location:
  • Phone: 612-822-7021
  • Fax: 612-822-6123
Mailing address:
  • Phone: 612-822-7021
  • Fax: 612-822-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2219
License Number StateMN

VIII. Authorized Official

Name: DR. LINDA MARIE CHOUS
Title or Position: OWNER
Credential: O.D.
Phone: 612-822-7021