Healthcare Provider Details

I. General information

NPI: 1407927734
Provider Name (Legal Business Name): DAVID THELEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 LEWIS AVE S SUITE 102
WATERTOWN MN
55388-4500
US

IV. Provider business mailing address

204 LEWIS AVE S SUITE 102
WATERTOWN MN
55388-4500
US

V. Phone/Fax

Practice location:
  • Phone: 952-955-3553
  • Fax: 952-955-1900
Mailing address:
  • Phone: 952-955-3553
  • Fax: 952-955-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: JANE THELEN
Title or Position: OWNER
Credential:
Phone: 763-295-4044