=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134274475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. PETER EYECARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 02/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 SUNRISE DR
-----------------------------------------------------
City | SAINT PETER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56082-1352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-931-6436
-----------------------------------------------------
Fax | 507-934-9625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 SUNRISE DR
-----------------------------------------------------
City | SAINT PETER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56082-1352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-931-6436
-----------------------------------------------------
Fax | 507-934-9625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. TERRI WINTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-931-6436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------