MEDICARE: EYE Q OPTOMETRIC CLINIC, LIMITED

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	2529	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	U58324	OTHER	MN	RAILROAD MEDICARE
3	1245428135	OTHER	MN	RAILROAD MEDICARE
4	C04933	OTHER	MN	RAILROAD MEDICARE PTAN
5	C04933	OTHER	MN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	5C956EY	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1245428135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE Q OPTOMETRIC CLINIC, LIMITED

Provider Business Mailing Address
First Line	:	201 NW 4TH ST
Second Line	:	SUITE 107
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-2753
Country	:	US
Telephone Number	:	218-326-9619
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 NW 4TH ST
Second Line	:	SUITE 107
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-2753
Country	:	US
Telephone Number	:	218-326-9619
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DARWIN DALEN
Credential	:
Telephone Number	:	218-326-9619

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	05/24/2016

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Directions to “EYE Q OPTOMETRIC CLINIC, LIMITED ” Practice Location

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