=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336588177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIRIUS VISION OPTOMETRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2013
-----------------------------------------------------
Last Update Date | 07/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1063 BURNSVILLE CTR
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55306-4447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-435-8821
-----------------------------------------------------
Fax | 952-435-8821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1063 BURNSVILLE CTR
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55306-4447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-435-8821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. PATRICK JOHN MARTIN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 952-435-8821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MN2093
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------