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General NPI Number Information
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NPI Number | 1861287583
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Entity Type | Individual
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Provider Name | CARLY VAN KEULEN
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Gender |
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Dates
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Enumeration Date | 04/12/2025
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Last Update Date | 06/17/2025
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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 |
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Provider Business Mailing Address
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Address Line | 1067 4TH ST NE STE 350
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City | BYRON
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State | MN
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Zip | 55920-5004
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4011
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License Number State | MN
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