Provider Demographics
NPI:1548580228
Name:MOOSE LAKE EYE CARE LLC
Entity type:Organization
Organization Name:MOOSE LAKE EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:NIRANJALI
Authorized Official - Last Name:NARAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-485-8495
Mailing Address - Street 1:312 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-7706
Mailing Address - Country:US
Mailing Address - Phone:218-485-8495
Mailing Address - Fax:218-485-8498
Practice Address - Street 1:312 ELM AVE
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-7706
Practice Address - Country:US
Practice Address - Phone:218-485-8495
Practice Address - Fax:218-485-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2979152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty