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NPI Code Detail

MEDICARE: CRISTELLE ELISE BOOTS OD

MEDICARE: CRISTELLE ELISE BOOTS OD
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
1152W00000XOptometrist18004193AIN
2152W00000XOptometrist3712MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
118004193AOTHERININDIANA STATE LICENSE

General Provider Information

NPI Number : 1699323162
Entity Type Code : Individual
Provider Name (Legal Business Name) : CRISTELLE ELISE BOOTS OD
Provider Business Mailing Address
First Line : 9801 DUPONT AVE S
Second Line : STE 425
City : BLOOMINGTON
State : MN
Zip : 55431-3873
Country : US
Telephone Number : 952-888-5800
Fax Number : 952-567-6176
Provider Business Practice Location Address
First Line : 11091 ULYSSES ST NE STE 300
Second Line :
City : BLAINE
State : MN
Zip : 55434-4238
Country : US
Telephone Number : 952-888-5800
Fax Number : 952-567-6156
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/28/2019
Last Update Date : 08/04/2023

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Directions to “ CRISTELLE ELISE BOOTS OD” Practice Location

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