MEDICARE: MINNESOTA OPTICAL 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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1962829580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA OPTICAL LLC

Provider Business Mailing Address
First Line	:	19576 HOLT ST NW
Second Line	:
City	:	ELK RIVER
State	:	MN
Zip	:	55330-1287
Country	:	US
Telephone Number	:	763-241-2083
Fax Number	:	763-241-3801

Provider Business Practice Location Address
First Line	:	3333 HAZELTON RD
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-4204
Country	:	US
Telephone Number	:	952-926-6149
Fax Number	:

Authorized Official
Title or Position	:	CHIEF MANAGER
Name	:	GARY C TONSAGER
Credential	:
Telephone Number	:	763-241-2083

Provider Enumeration Date	:	03/20/2014
Last Update Date	:	03/20/2014

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