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General NPI Number Information
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NPI Number | 1063457943
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Entity Type | Organization
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Legal Business Name | ELK RIVER EYE CLINIC, P.A.
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Dates
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Enumeration Date | 06/17/2006
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Last Update Date | 08/06/2010
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Provider Practice Location Address
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Address Line | 19022 FREEPORT AVE NW SUITE H
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City | ELK RIVER
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State | MN
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Zip | 55330-4767
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Country | US
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Telephone | 763-441-1055
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Fax | 763-441-7024
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Provider Business Mailing Address
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Address Line | 19022 FREEPORT AVE NW SUITE H
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City | ELK RIVER
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State | MN
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Zip | 55330-4767
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Country | US
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Telephone | 763-441-1055
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Fax | 763-441-7024
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY MARK HOFFARD
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Credential | O.D.
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Telephone | 763-441-1055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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