Healthcare Provider Details

I. General information

NPI: 1932882230
Provider Name (Legal Business Name): MINNESOTA EYE LASER & SURGERY CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 WHITEWATER DR STE 320
MINNETONKA MN
55343-9436
US

IV. Provider business mailing address

9801 DUPONT AVE S STE 425
BLOOMINGTON MN
55431-3873
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-5800
  • Fax: 952-567-6156
Mailing address:
  • Phone: 952-888-5800
  • Fax: 952-567-6156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLIFTON CHAD BAZHAW
Title or Position: SR. VP REVENUE CYCLE
Credential:
Phone: 469-270-6658