=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245303825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COKATO EYE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 OLSEN BLVD
-----------------------------------------------------
City | COKATO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-286-5695
-----------------------------------------------------
Fax | 320-286-5742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1060 115 OLSEN BLVD
-----------------------------------------------------
City | COKATO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-286-5695
-----------------------------------------------------
Fax | 320-286-5742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROJECT LEAD
-----------------------------------------------------
Name | SHANDA LARSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-286-5695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------