Healthcare Provider Details

I. General information

NPI: 1164448627
Provider Name (Legal Business Name): CROSSROADS OPTOMETRIC CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16250 DULUTH AVE SE STE 100
PRIOR LAKE MN
55372-2883
US

IV. Provider business mailing address

16250 DULUTH AVE SE STE 100
PRIOR LAKE MN
55372-2883
US

V. Phone/Fax

Practice location:
  • Phone: 952-447-2020
  • Fax: 952-447-2322
Mailing address:
  • Phone: 952-447-2020
  • Fax: 952-447-2322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0001425
License Number StateMN

VIII. Authorized Official

Name: LISA ANNE DAWSON-CLAUSEN
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 952-447-2020