Healthcare Provider Details

I. General information

NPI: 1245629369
Provider Name (Legal Business Name): EYECARE MPLS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 EXCELSIOR BLVD SUITE 205
MINNEAPOLIS MN
55416-4688
US

IV. Provider business mailing address

3033 EXCELSIOR BLVD SUITE 205
MINNEAPOLIS MN
55416-4688
US

V. Phone/Fax

Practice location:
  • Phone: 612-470-9871
  • Fax:
Mailing address:
  • Phone: 612-470-9871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number56474
License Number StateMN

VIII. Authorized Official

Name: DR. STELLA HENNEN
Title or Position: GLAUCOMA SPECIALIST/OWNER
Credential: MD, MSPH
Phone: 612-470-9871