Healthcare Provider Details

I. General information

NPI: 1518928845
Provider Name (Legal Business Name): TIMOTHY J HURLEY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 HIGHWAY 169 N
PLYMOUTH MN
55442-2897
US

IV. Provider business mailing address

9126 LARCH LN N
MAPLE GROVE MN
55369-3972
US

V. Phone/Fax

Practice location:
  • Phone: 763-551-0529
  • Fax:
Mailing address:
  • Phone: 763-315-1464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2688
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: