=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194912386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORDIN EYE CARE ASSOCIATES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13020 RIVERDALE DR NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55448-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-421-9652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 256 JOHNSON PKWY
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106-6410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-774-7538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. ALEISHA JOO NORDIN
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 763-421-9562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2924
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------