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General NPI Number Information
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NPI Number | 1780023879
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Entity Type | Organization
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Legal Business Name | SIRIUS VISION OPTICAL INC
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Dates
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Enumeration Date | 06/21/2013
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Last Update Date | 06/21/2013
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Provider Practice Location Address
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Address Line | 1056 BURNSVILLE CTR
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City | BURNSVILLE
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State | MN
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Zip | 55306-4408
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Country | US
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Telephone | 952-435-8821
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Fax | 952-435-1624
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Provider Business Mailing Address
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Address Line | 1056 BURNSVILLE CTR
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City | BURNSVILLE
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State | MN
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Zip | 55306-4408
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Country | US
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Telephone | 952-435-8821
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Fax | 952-435-1624
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. PATRICK JOHN MARTIN
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Credential | O.D.
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Telephone | 952-435-8821
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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 | 2093
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License Number State | MN
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