Healthcare Provider Details

I. General information

NPI: 1982028312
Provider Name (Legal Business Name): G MABIE EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 GENEVA AVE N
OAKDALE MN
55128-4108
US

IV. Provider business mailing address

1955 GENEVA AVE N
OAKDALE MN
55128-4108
US

V. Phone/Fax

Practice location:
  • Phone: 651-702-2504
  • Fax:
Mailing address:
  • Phone: 651-702-2504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2593
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number096034
License Number StateMN

VIII. Authorized Official

Name: DR. SARA MABIE
Title or Position: PRESIDENT
Credential: OD
Phone: 651-702-2504