Healthcare Provider Details

I. General information

NPI: 1679643100
Provider Name (Legal Business Name): F & G OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 LAKE ST E UNIT A
WAYZATA MN
55391-4523
US

IV. Provider business mailing address

852 LAKE ST E UNIT A
WAYZATA MN
55391-4526
US

V. Phone/Fax

Practice location:
  • Phone: 952-476-4185
  • Fax: 952-476-8812
Mailing address:
  • Phone: 952-476-4185
  • Fax: 952-476-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2439
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. VIRGINIA DOMAIN
Title or Position: CFO
Credential:
Phone: 952-476-4185