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General NPI Number Information
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NPI Number | 1790029742
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Entity Type | Organization
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Legal Business Name | VIVIAN EKEMEZIE, O.D
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 07/17/2013
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Provider Practice Location Address
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Address Line | 215 BALSAM ST N
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City | CAMBRIDGE
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State | MN
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Zip | 55008-5814
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Country | US
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Telephone | 763-689-5576
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Fax | 763-689-3792
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Provider Business Mailing Address
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Address Line | 1036 97TH LN NE
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City | BLAINE
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State | MN
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Zip | 55434-3515
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Country | US
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Telephone | 763-843-7153
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. VIVIAN OWANIMEDU EKEMEZIE
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Credential | O.D
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Telephone | 763-843-7153
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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 | 3311
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License Number State | MN
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