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General NPI Number Information
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NPI Number | 1700263985
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Entity Type | Organization
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Legal Business Name | MOOSE LAKE EYE CARE, LLC
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Dates
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Enumeration Date | 04/27/2015
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Last Update Date | 04/27/2015
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Provider Practice Location Address
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Address Line | 45 LADY LUCK DR. SUITE 120
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City | HINCKLEY
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State | MN
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Zip | 55037
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Country | US
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Telephone | 320-384-6361
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Fax | 320-384-6361
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Provider Business Mailing Address
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Address Line | PO BOX 728
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City | HINCKLEY
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State | MN
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Zip | 55037-0728
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Country | US
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Telephone | 320-384-6361
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Fax | 320-384-6361
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Authorized Official
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Title or Position | PRESIDENT
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Name | SASHA N NARAYAN
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Credential | O.D.
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Telephone | 218-485-8495
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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 | 152W00000X
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License Number State | MN
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