=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871576306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHDALE OPTICAL CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2005
-----------------------------------------------------
Last Update Date | 06/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6533 DREW AVE S
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-925-9550
-----------------------------------------------------
Fax | 952-925-9748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6533 DREW AVE S
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-925-9550
-----------------------------------------------------
Fax | 952-925-9748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BRADLEY JON PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-925-9550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------