=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083737159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST EYE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W HIGHWAY 212
-----------------------------------------------------
City | NORWOOD YOUNG AMERICA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55368-9775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-467-2250
-----------------------------------------------------
Fax | 952-467-2270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1464 WHITE OAK DR
-----------------------------------------------------
City | CHASKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55318-2525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-466-3937
-----------------------------------------------------
Fax | 952-466-3936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MS. KRISTI LEANN NARUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-466-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2627
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------