Provider Demographics
NPI:1003813635
Name:RED WING OPTOMETRIC CLINIC, P.A.
Entity Type:Organization
Organization Name:RED WING OPTOMETRIC CLINIC, P.A.
Other - Org Name:EYE CARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-388-9187
Mailing Address - Street 1:164 TYLER RD S
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-1733
Mailing Address - Country:US
Mailing Address - Phone:651-388-9187
Mailing Address - Fax:
Practice Address - Street 1:164 TYLER RD S
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-1733
Practice Address - Country:US
Practice Address - Phone:651-388-9187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11707OtherUCARE
MN2200260OtherMEDICA
MN0149240001OtherDMEPOS
MN1007983OtherPREFERRED ONE
MN4C831PAOtherBLUE CROSS BLUE SHIELD
MN5C066REOtherBLUE PLUS EYEWEAR
MN64216REOtherBLUE PLUS EXAMS
MN11707OtherUCARE
MN=========OtherSELECTCARE
MN2200260OtherMEDICA
MN=========OtherNORTH AMERICAN ADMINISTRA
MN=========OtherNORTH AMERICAN ADMINISTRA