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General NPI Number Information
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NPI Number | 1679675680
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Entity Type | Organization
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Legal Business Name | BLUE EARTH VALLEY EYE CLINIC LTD
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Dates
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Enumeration Date | 09/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 21 MAIN STREET SOUTH
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City | WINNEBAGO
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State | MN
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Zip | 56098
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Country | US
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Telephone | 507-893-4532
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Fax | 507-893-4854
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Provider Business Mailing Address
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Address Line | PO BOX 717
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City | WINNEBAGO
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State | MN
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Zip | 56098
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Country | US
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Telephone | 507-893-4532
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Fax | 507-893-4854
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRENT DANIEL JOHNSON
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Credential |
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Telephone | 507-893-4532
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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