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General NPI Number Information
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NPI Number | 1609921899
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Entity Type | Organization
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Legal Business Name | BIRCH LAKE VISION GROUP, LLC.
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 12/02/2009
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Provider Practice Location Address
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Address Line | 4720 WHITE BEAR PKWY
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-3336
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Country | US
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Telephone | 651-426-2747
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Fax | 651-426-9838
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Provider Business Mailing Address
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Address Line | 4720 WHITE BEAR PKWY
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-3336
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Country | US
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Telephone | 651-426-2747
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Fax | 651-426-9838
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Authorized Official
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Title or Position | CFO
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Name | DR. BRIAN DWIGHT GRUDEM
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Credential | O.D.
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Telephone | 651-426-2747
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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 | LD2695000
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | LD1732000
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License Number State | MN
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