Healthcare Provider Details

I. General information

NPI: 1578595294
Provider Name (Legal Business Name): ROGER LEE RENGEL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 VILLAGE CENTER DR SUITE 180
NORTH OAKS MN
55127-3019
US

IV. Provider business mailing address

700 VILLAGE CENTER DR SUITE 180
NORTH OAKS MN
55127-3019
US

V. Phone/Fax

Practice location:
  • Phone: 651-482-1959
  • Fax: 651-482-1850
Mailing address:
  • Phone: 651-482-1959
  • Fax: 651-482-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1622
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: