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General NPI Number Information
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NPI Number | 1770913626
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Entity Type | Organization
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Legal Business Name | ICARE OPTICAL, LLC
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Dates
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Enumeration Date | 11/13/2013
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Last Update Date | 11/13/2013
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Provider Practice Location Address
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Address Line | 1001 JOHNSON PKWY STE 271
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City | SAINT PAUL
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State | MN
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Zip | 55106-3474
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Country | US
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Telephone | 651-315-1766
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Fax | 651-318-3651
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Provider Business Mailing Address
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Address Line | 1815 ROSS AVE E
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City | SAINT PAUL
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State | MN
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Zip | 55119-3431
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Country | US
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Telephone | 651-315-1766
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Fax | 651-318-3651
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHONBURI LEE
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Credential |
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Telephone | 651-373-0914
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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