MEDICARE: ST. PAUL OPTICIANS, INC.

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1134557432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. PAUL OPTICIANS, INC.

Provider Business Mailing Address
First Line	:	2080 WOODWINDS DR
Second Line	:	SUITE 110
City	:	WOODBURY
State	:	MN
Zip	:	55125-2523
Country	:	US
Telephone Number	:	651-738-6800
Fax Number	:	651-714-6997

Provider Business Practice Location Address
First Line	:	1675 BEAM AVE
Second Line	:	SUITE 100
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-1172
Country	:	US
Telephone Number	:	651-770-2904
Fax Number	:	651-770-5746

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. THOMAS J. RICE
Credential	:	M.D.
Telephone Number	:	651-738-6800

Provider Enumeration Date	:	10/23/2013
Last Update Date	:	10/23/2013

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