MEDICARE: BLUE EARTH VALLEY EYE CLINIC LTD

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1518950708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE EARTH VALLEY EYE CLINIC LTD

Provider Business Mailing Address
First Line	:	PO BOX 36
Second Line	:
City	:	BLUE EARTH
State	:	MN
Zip	:	56013-0036
Country	:	US
Telephone Number	:	507-526-2222
Fax Number	:	507-526-3927

Provider Business Practice Location Address
First Line	:	435 S GROVE ST
Second Line	:
City	:	BLUE EARTH
State	:	MN
Zip	:	56013-2604
Country	:	US
Telephone Number	:	507-526-2222
Fax Number	:	507-526-3927

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRENT DANIEL JOHNSON
Credential	:	OD
Telephone Number	:	507-526-2222

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	08/22/2020

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