Provider Demographics
NPI:1053504779
Name:TLC OF THE TWIN CITIES
Entity Type:Organization
Organization Name:TLC OF THE TWIN CITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-420-4026
Mailing Address - Street 1:16555 77TH CIR N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3734
Mailing Address - Country:US
Mailing Address - Phone:763-420-4026
Mailing Address - Fax:
Practice Address - Street 1:11330 FOUNTAINS DR
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7200
Practice Address - Country:US
Practice Address - Phone:763-494-8061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN334M3WAOtherBCBS
MN2202630OtherMEDICA
MN297601016602OtherPREF ONE
MNU59524OtherUPIN