=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205930542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINNESOTA EYE CONSULTANTS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9801 DUPONT AVE S SUITE 425
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-567-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9801 DUPONT AVE S SUITE 425
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-567-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CANDACE SIMERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-567-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1751
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------