Healthcare Provider Details

I. General information

NPI: 1366752248
Provider Name (Legal Business Name): SHANE JAHRAUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

IV. Provider business mailing address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-2020
  • Fax:
Mailing address:
  • Phone: 320-235-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3341
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: