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General NPI Number Information
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NPI Number | 1851585822
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Entity Type | Organization
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Legal Business Name | GIBBONS OPTICAL, LLC
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Dates
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Enumeration Date | 08/31/2007
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Last Update Date | 05/27/2008
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Provider Practice Location Address
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Address Line | 150 17TH AVE NW
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City | ROCHESTER
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State | MN
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Zip | 55901-0321
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Country | US
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Telephone | 507-288-6964
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Fax | 507-252-5307
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Provider Business Mailing Address
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Address Line | 150 17TH AVE NW
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City | ROCHESTER
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State | MN
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Zip | 55901-0321
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Country | US
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Telephone | 507-288-6964
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Fax | 507-252-5307
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. KAREN MARIE BJORNGAARD
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Credential | O.D.
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Telephone | 507-288-6964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 2343
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License Number State | MN
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