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General NPI Number Information
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NPI Number | 1760089700
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Entity Type | Organization
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Legal Business Name | EAGAN EYE CLINIC LLC
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Dates
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Enumeration Date | 10/02/2020
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Last Update Date | 10/02/2020
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Provider Practice Location Address
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Address Line | 206 DIVISION ST
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City | WAITE PARK
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State | MN
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Zip | 56387-1331
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Country | US
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Telephone | 320-235-0365
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Fax |
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Provider Business Mailing Address
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Address Line | 211 E BROADWAY
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City | ALTON
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State | IL
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Zip | 62002-6220
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Country | US
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Telephone | 618-462-9818
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BENJAMIN S. CHUDNER
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Credential | OD
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Telephone | 972-370-5552
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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 |
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License Number State |
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