Healthcare Provider Details

I. General information

NPI: 1306161187
Provider Name (Legal Business Name): CHARLES R MEAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 WOODLANE DR
WOODBURY MN
55125-2221
US

IV. Provider business mailing address

1502 WOODLANE DR
WOODBURY MN
55125-2221
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-9550
  • Fax: 651-735-9322
Mailing address:
  • Phone: 651-735-9550
  • Fax: 651-735-9322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: AUDREY MEAD
Title or Position: PRACTICE MANAGER
Credential:
Phone: 651-735-9550