Healthcare Provider Details

I. General information

NPI: 1841337425
Provider Name (Legal Business Name): WAYNE GENE HINES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14120 COMMERCE AVE NE SUITE 100
PRIOR LAKE MN
55372-1500
US

IV. Provider business mailing address

5270 SAINT ALBANS BAY RD
EXCELSIOR MN
55331-8635
US

V. Phone/Fax

Practice location:
  • Phone: 952-447-2020
  • Fax: 952-447-2322
Mailing address:
  • Phone: 952-474-2654
  • Fax: 952-474-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: