Healthcare Provider Details

I. General information

NPI: 1770701047
Provider Name (Legal Business Name): MINNESOTA EYECARE NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SOUTH BROADWAY
PELICAN RAPIDS MN
56572
US

IV. Provider business mailing address

20 SOUTH BROADWAY PO BOX 474
PELICAN RAPIDS MN
56572
US

V. Phone/Fax

Practice location:
  • Phone: 218-863-7061
  • Fax: 218-863-7062
Mailing address:
  • Phone: 218-863-7061
  • Fax: 218-863-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TIMOTHY C NEITZKE
Title or Position: PRESIDENT
Credential: OD
Phone: 218-346-3310