Provider Demographics
NPI:1144494410
Name:MADELIA OPTOMETRIC, INC.
Entity type:Organization
Organization Name:MADELIA OPTOMETRIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-642-3853
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:MADELIA
Mailing Address - State:MN
Mailing Address - Zip Code:56062-0190
Mailing Address - Country:US
Mailing Address - Phone:507-642-3853
Mailing Address - Fax:507-642-3854
Practice Address - Street 1:18 BENZEL AVE NW
Practice Address - Street 2:
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1422
Practice Address - Country:US
Practice Address - Phone:507-642-3853
Practice Address - Fax:507-642-3854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN262M6MAOtherBLUE CROSS BLUE SHIELD OF MN
MN120152200Medicaid
MN4857150001Medicare NSC