MEDICARE: PHAM-VANG OPTOMETRY LLC

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	302F00000X	Exclusive Provider Organization	3056	MN
2	152W00000X	Optometrist	3056	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C05200	OTHER	MN	PTAN
2	1689607780	OTHER	MN	INDIVIDUAL NPI
3	1831330679	OTHER	MN	GROUP NPI

General Provider Information

NPI Number	:	1831330679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHAM-VANG OPTOMETRY LLC

Provider Business Mailing Address
First Line	:	7074 BROOKLYN BLVD
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1370
Country	:	US
Telephone Number	:	763-316-4193
Fax Number	:	763-363-0002

Provider Business Practice Location Address
First Line	:	7074 BROOKLYN BLVD
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1370
Country	:	US
Telephone Number	:	763-316-4193
Fax Number	:	763-363-0002

Authorized Official
Title or Position	:	CEO
Name	:	DR. SANDY PHAM-VANG
Credential	:	OD
Telephone Number	:	763-639-0103

Provider Enumeration Date	:	03/06/2009
Last Update Date	:	11/08/2023

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Directions to “PHAM-VANG OPTOMETRY LLC ” Practice Location

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