Healthcare Provider Details

I. General information

NPI: 1477728418
Provider Name (Legal Business Name): INDEX 53 OPT ICAL CO.INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 MAIN ST E
ST STEPHEN MN
56375
US

IV. Provider business mailing address

PO BOX 1111
ST CLOUD MN
56302
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-9380
  • Fax: 320-654-9502
Mailing address:
  • Phone: 320-252-9380
  • Fax: 320-654-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE A RUDOLPH
Title or Position: PRES OPTICIAN
Credential:
Phone: 320-252-9380