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General NPI Number Information
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NPI Number | 1245428135
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Entity Type | Organization
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Legal Business Name | EYE Q OPTOMETRIC CLINIC, LIMITED
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Dates
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Enumeration Date | 10/04/2007
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Last Update Date | 05/24/2016
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Provider Practice Location Address
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Address Line | 201 NW 4TH ST SUITE 107
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-2753
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Country | US
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Telephone | 218-326-9619
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Fax |
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Provider Business Mailing Address
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Address Line | 201 NW 4TH ST SUITE 107
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-2753
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Country | US
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Telephone | 218-326-9619
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DARWIN DALEN
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Credential |
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Telephone | 218-326-9619
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 2529
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License Number State | MN
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