Healthcare Provider Details

I. General information

NPI: 1720982010
Provider Name (Legal Business Name): NORTHWEST EYE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 39TH AVE NE STE 1
ST. ANTHONY MN
55421-4372
US

IV. Provider business mailing address

8401 GOLDEN VALLEY RD STE 330
GOLDEN VALLEY MN
55427-4687
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-7600
  • Fax: 763-416-7634
Mailing address:
  • Phone: 763-416-7600
  • Fax: 763-416-7634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL

VIII. Authorized Official

Name: CLIFTON CHAD BAZHAW
Title or Position: CHIEF REVENUE OFFICER
Credential:
Phone: 214-893-0471