MEDICARE: ICARE FAMILY VISION PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3225	MN

General Provider Information

NPI Number	:	1003359597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICARE FAMILY VISION PLC

Provider Business Mailing Address
First Line	:	6900 W LAKE ST
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-4209
Country	:	US
Telephone Number	:	952-222-3578
Fax Number	:

Provider Business Practice Location Address
First Line	:	6900 W LAKE ST
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-4209
Country	:	US
Telephone Number	:	952-222-3578
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH JOHNSON
Credential	:
Telephone Number	:	952-222-3578

Provider Enumeration Date	:	12/01/2016
Last Update Date	:	10/25/2022

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