MEDICARE: L.M. AFFOLTER O.D.

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	1370	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46009AF	OTHER	MN	BCBS
2	5C002AF	OTHER	MN	BCBS
3	11257	OTHER	MN	UCARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	930531027150	OTHER	MN	PREFERRED

General Provider Information

NPI Number	:	1588835649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L.M. AFFOLTER O.D.

Provider Business Mailing Address
First Line	:	121 N 3RD ST
Second Line	:
City	:	MARSHALL
State	:	MN
Zip	:	56258-1324
Country	:	US
Telephone Number	:	507-532-5143
Fax Number	:	507-532-5143

Provider Business Practice Location Address
First Line	:	121 N 3RD ST
Second Line	:
City	:	MARSHALL
State	:	MN
Zip	:	56258-1324
Country	:	US
Telephone Number	:	507-532-5143
Fax Number	:	507-532-5143

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LEROY M AFFOLTER
Credential	:	O.DO
Telephone Number	:	507-532-5143

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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