Provider Demographics
NPI:1730203597
Name:OPTOMETRIC EYE CARE CENTERS, PA
Entity type:Organization
Organization Name:OPTOMETRIC EYE CARE CENTERS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KRAUPA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-777-3555
Mailing Address - Street 1:1965 11TH AVE E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5167
Mailing Address - Country:US
Mailing Address - Phone:651-777-3555
Mailing Address - Fax:651-777-4459
Practice Address - Street 1:1965 11TH AVE E
Practice Address - Street 2:SUITE 101
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5167
Practice Address - Country:US
Practice Address - Phone:651-777-3555
Practice Address - Fax:651-777-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN08072KROtherBCBS OF MN PRACTICE GRP
MN2115755OtherMEDICA MN
MN581713700Medicaid
MN2115755OtherMEDICA MN
MN581713700Medicaid
MNC01332Medicare ID - Type UnspecifiedPRACTICE GROUP NUMBER