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NPI Code Detail

MEDICARE: CEDAR LAKES EYE SPECIALISTS PA

MEDICARE: CEDAR LAKES EYE SPECIALISTS PA
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
1152W00000XOptometrist3009MN

General Provider Information

NPI Number : 1730472523
Entity Type Code : Organization
Provider Name (Legal Business Name) : CEDAR LAKES EYE SPECIALISTS PA
Provider Business Mailing Address
First Line : PO BOX 1170
Second Line :
City : MAPLE GROVE
State : MN
Zip : 55311-6170
Country : US
Telephone Number : 763-582-9601
Fax Number : 763-582-9613
Provider Business Practice Location Address
First Line : 5801 W 16TH ST
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55416-1446
Country : US
Telephone Number : 763-582-9601
Fax Number : 763-582-9613
Authorized Official
Title or Position : OWNER
Name : MR. DAVID BANE
Credential : OD
Telephone Number : 763-582-9601
Provider Enumeration Date : 05/26/2011
Last Update Date : 04/30/2018

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