Healthcare Provider Details

I. General information

NPI: 1235282633
Provider Name (Legal Business Name): OAKDALE OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7013 10TH ST N
OAKDALE MN
55128-5938
US

IV. Provider business mailing address

7013 10TH ST N
OAKDALE MN
55128-5938
US

V. Phone/Fax

Practice location:
  • Phone: 651-738-8040
  • Fax: 651-714-0759
Mailing address:
  • Phone: 651-738-8040
  • Fax: 651-714-0759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1460
License Number StateMN

VIII. Authorized Official

Name: JOHN M ELVERUM
Title or Position: OWNER
Credential: OD
Phone: 651-738-8040