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General NPI Number Information
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NPI Number | 1164448627
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Entity Type | Organization
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Legal Business Name | CROSSROADS OPTOMETRIC CLINIC, INC.
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 12/08/2020
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Provider Practice Location Address
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Address Line | 16250 DULUTH AVE SE STE 100
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City | PRIOR LAKE
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State | MN
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Zip | 55372-2883
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Country | US
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Telephone | 952-447-2020
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Fax | 952-447-2322
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Provider Business Mailing Address
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Address Line | 16250 DULUTH AVE SE STE 100
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City | PRIOR LAKE
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State | MN
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Zip | 55372-2883
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Country | US
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Telephone | 952-447-2020
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Fax | 952-447-2322
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | LISA ANNE DAWSON-CLAUSEN
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Credential | OD
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Telephone | 952-447-2020
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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 | 0001425
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License Number State | MN
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