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General NPI Number Information
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NPI Number | 1093888349
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Entity Type | Organization
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Legal Business Name | ADVANCED VISION CLINIC AND OPTICAL LLC
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1099 HELMO AVE N SUITE 150
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City | OAKDALE
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State | MN
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Zip | 55128-6033
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Country | US
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Telephone | 651-739-3937
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Fax | 651-739-9690
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Provider Business Mailing Address
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Address Line | 1099 HELMO AVE N SUITE 150
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City | OAKDALE
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State | MN
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Zip | 55128-6033
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Country | US
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Telephone | 651-739-3937
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Fax | 651-739-9690
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Authorized Official
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Title or Position | OWNER MEMBER
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Name | ANGELA PORCH JOHNSON
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Credential | OD
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Telephone | 651-270-1621
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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 | 2955
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License Number State | MN
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