Healthcare Provider Details

I. General information

NPI: 1073004289
Provider Name (Legal Business Name): WHITNEY STOCK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

IV. Provider business mailing address

13900 NORTHDALE BLVD
ROGERS MN
55374-9627
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-2020
  • Fax:
Mailing address:
  • Phone: 763-428-3757
  • Fax: 763-428-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3557
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: