Provider Demographics
NPI:1760511398
Name:ACKERMANN TOTAL EYE CARE INC
Entity type:Organization
Organization Name:ACKERMANN TOTAL EYE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ACKERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-345-3039
Mailing Address - Street 1:117 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1635
Mailing Address - Country:US
Mailing Address - Phone:651-345-3039
Mailing Address - Fax:651-345-3506
Practice Address - Street 1:117 W CENTER ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1635
Practice Address - Country:US
Practice Address - Phone:651-345-3039
Practice Address - Fax:651-345-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263917000Medicaid
MN80G68ACOtherBLUE CROSS BLUE SHIELD
MN263917000Medicaid
MN410002610Medicare PIN