Healthcare Provider Details

I. General information

NPI: 1417982935
Provider Name (Legal Business Name): SAM'S CLUB OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 55TH ST NW
ROCHESTER MN
55901-0123
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-6209
US

V. Phone/Fax

Practice location:
  • Phone: 507-281-8355
  • Fax: 479-277-8176
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: LAURIE SUE HAYNES
Title or Position: SUPERVISOR
Credential:
Phone: 479-204-8495