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General NPI Number Information
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NPI Number | 1457563827
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Entity Type | Organization
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Legal Business Name | MINNESOTA VISION OUTREACH, INC
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Dates
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Enumeration Date | 05/05/2007
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Last Update Date | 11/10/2016
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Provider Practice Location Address
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Address Line | 9905 45TH AVENUE NORTH SUITE 110
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City | PLYMOUTH
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State | MN
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Zip | 55422-3315
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Country | US
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Telephone | 763-595-8414
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Fax | 763-595-8414
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Provider Business Mailing Address
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Address Line | 9905 45TH AVENUE NORTH SUITE 110
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City | PLYMOUTH
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State | MN
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Zip | 55422-3315
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Country | US
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Telephone | 763-595-8414
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Fax | 763-595-8438
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAMUEL WOLFSON
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Credential | O.D.
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Telephone | 763-585-8414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1706
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License Number State | MN
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