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General NPI Number Information
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NPI Number | 1821113804
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Entity Type | Organization
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Legal Business Name | GIBBONS EYE CLINIC, OPTOMETRISTS, P.A.
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 07/10/2008
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Provider Practice Location Address
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Address Line | 120 MAIN ST N
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City | CAMBRIDGE
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State | MN
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Zip | 55008-1230
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Country | US
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Telephone | 763-689-1441
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Fax | 763-689-3925
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Provider Business Mailing Address
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Address Line | 120 MAIN ST N
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City | CAMBRIDGE
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State | MN
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Zip | 55008-1230
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Country | US
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Telephone | 763-689-1441
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Fax | 763-689-3925
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Authorized Official
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Title or Position | MANAGER
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Name | MS. PAULA RAE NEU
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Credential |
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Telephone | 763-689-1441
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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 | 1978
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License Number State | MN
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