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General NPI Number Information
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NPI Number | 1861465064
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Entity Type | Organization
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Legal Business Name | MINNESOTA EYE CONSULTANTS, PA
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 02/22/2017
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Provider Practice Location Address
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Address Line | 1965 11TH AVE E SUITE 102
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City | MAPLEWOOD
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State | MN
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Zip | 55109-5167
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Country | US
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Telephone | 952-888-5800
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Fax | 651-748-4445
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Provider Business Mailing Address
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Address Line | 9801 DUPONT AVE S SUITE 425
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City | BLOOMINGTON
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State | MN
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Zip | 55431-3100
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Country | US
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Telephone | 952-888-5800
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Fax | 952-567-6156
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRENT L WILDE
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Credential |
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Telephone | 952-888-5800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 24D2023181
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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