Provider Demographics
NPI:1902943822
Name:PLYMOUTH VISION CENTER, INC.
Entity Type:Organization
Organization Name:PLYMOUTH VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TATE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-559-4669
Mailing Address - Street 1:3007 HARBOR LN N STE 1500
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5103
Mailing Address - Country:US
Mailing Address - Phone:763-559-4669
Mailing Address - Fax:763-559-4767
Practice Address - Street 1:3007 HARBOR LN N STE 1500
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5103
Practice Address - Country:US
Practice Address - Phone:763-559-4669
Practice Address - Fax:763-559-4767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16F68PLOtherBS OF MN
MNC04133Medicare ID - Type Unspecified
MN4075590001Medicare NSC