Healthcare Provider Details

I. General information

NPI: 1407960651
Provider Name (Legal Business Name): MINNESOTA EYECARE NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 FOX STREET
PERHAM MN
56573-1733
US

IV. Provider business mailing address

652 JEFFERSON STREET
WADENA MN
56482-2307
US

V. Phone/Fax

Practice location:
  • Phone: 218-346-3310
  • Fax: 218-346-3310
Mailing address:
  • Phone: 218-631-1456
  • Fax: 218-631-3213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY C NEITZKE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 218-346-3310