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General NPI Number Information
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NPI Number | 1861675290
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Entity Type | Organization
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Legal Business Name | OPTOMETRIC VISION SERVICES PA
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Dates
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Enumeration Date | 12/07/2007
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Last Update Date | 12/07/2007
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Provider Practice Location Address
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Address Line | 7000 YORK AVE S
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City | EDINA
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State | MN
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Zip | 55435-4213
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Country | US
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Telephone | 952-922-8118
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Fax |
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Provider Business Mailing Address
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Address Line | 150 E TRAVELERS TRL SUITE D
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City | BURNSVILLE
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State | MN
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Zip | 55337-6889
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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 | OFFICER
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Name | GREG MACIK
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Credential | OD
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Telephone | 952-913-7520
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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 |
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License Number State |
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