Healthcare Provider Details

I. General information

NPI: 1932327202
Provider Name (Legal Business Name): MINNESOTA EYECARE NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 JEFFERSON ST S
WADENA MN
56482-1533
US

IV. Provider business mailing address

315 JEFFERSON ST S PO BOX 146
WADENA MN
56482-1533
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-1456
  • Fax: 218-631-3213
Mailing address:
  • Phone: 218-631-1456
  • Fax: 218-631-3213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. TIMOTHY C NEITZKE
Title or Position: PRESIDENT
Credential: OD
Phone: 218-631-1456