Healthcare Provider Details

I. General information

NPI: 1902932965
Provider Name (Legal Business Name): RIVER LAKE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 E LAKE ST
MINNEAPOLIS MN
55406-2307
US

IV. Provider business mailing address

4323 E LAKE ST
MINNEAPOLIS MN
55406-2307
US

V. Phone/Fax

Practice location:
  • Phone: 612-722-1003
  • Fax: 612-721-6336
Mailing address:
  • Phone: 612-722-1003
  • Fax: 612-721-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number1652
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1652
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3331
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3331
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number3331
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3331
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number3331
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP2754
License Number StateMN
# 9
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLP2754
License Number StateMN
# 10
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP2754
License Number StateMN
# 11
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberLP2754
License Number StateMN
# 12
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP2754
License Number StateMN
# 13
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP2754
License Number StateMN
# 14
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1652
License Number StateMN

VIII. Authorized Official

Name: DR. MICHEL E. HANEN-SMITH
Title or Position: MEMBER
Credential: O. D., M. S.
Phone: 612-722-1003