Healthcare Provider Details

I. General information

NPI: 1821366683
Provider Name (Legal Business Name): STAPLES EYE CLINIC PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 US 10 EAST
STAPLES MN
56479
US

IV. Provider business mailing address

922 US 10 EAST
STAPLES MN
56479-2428
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1331
  • Fax: 218-895-1332
Mailing address:
  • Phone: 218-894-1331
  • Fax: 218-895-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3172
License Number StateMN

VIII. Authorized Official

Name: DR. SETH ALAN DOKKEN
Title or Position: PRESIDENT
Credential:
Phone: 218-894-1331