Healthcare Provider Details

I. General information

NPI: 1710903562
Provider Name (Legal Business Name): REBECCA J HOFER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/19/2020
Certification Date: 01/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 GREAT OAK DR
WAITE PARK MN
56387-2504
US

IV. Provider business mailing address

414 GREAT OAK DR
WAITE PARK MN
56387-2504
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8061
  • Fax:
Mailing address:
  • Phone: 320-251-8061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3021
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMN3021
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: