Provider Demographics
NPI:1538624341
Name:DON SEALOCK, O.D., P.A.
Entity type:Organization
Organization Name:DON SEALOCK, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECR/TREAS
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SEALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-559-7358
Mailing Address - Street 1:4455 HIGHWAY 169 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2897
Mailing Address - Country:US
Mailing Address - Phone:763-559-7358
Mailing Address - Fax:763-559-6010
Practice Address - Street 1:9825 HOSPITAL DR # 106
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4479
Practice Address - Country:US
Practice Address - Phone:763-568-7177
Practice Address - Fax:763-568-7361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DON SEALOCK, O.D., P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier