Provider Demographics
NPI:1861941312
Name:DON SEALOCK, O.D., P.A.
Entity type:Organization
Organization Name:DON SEALOCK, O.D., P.A.
Other - Org Name:<UNAVAIL>
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:763-551-0529
Mailing Address - Street 1:2169 COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1570
Mailing Address - Country:US
Mailing Address - Phone:952-472-3366
Mailing Address - Fax:952-491-4571
Practice Address - Street 1:2169 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1570
Practice Address - Country:US
Practice Address - Phone:952-472-3366
Practice Address - Fax:952-491-4571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DON SEALOCK, O.D., P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier