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General NPI Number Information
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NPI Number | 1003813635
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Entity Type | Organization
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Legal Business Name | RED WING OPTOMETRIC CLINIC, P.A.
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Dates
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Enumeration Date | 06/28/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 164 TYLER RD S
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City | RED WING
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State | MN
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Zip | 55066-1733
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Country | US
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Telephone | 651-388-9187
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Fax |
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Provider Business Mailing Address
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Address Line | 164 TYLER RD S
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City | RED WING
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State | MN
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Zip | 55066-1733
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Country | US
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Telephone | 651-388-9187
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | CHRIS J PALMER
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Credential | OD
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Telephone | 651-388-9187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2513
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License Number State | MN
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