Provider Demographics
NPI:1063457943
Name:ELK RIVER EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:ELK RIVER EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:HOFFARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-441-1055
Mailing Address - Street 1:19022 FREEPORT AVE NW
Mailing Address - Street 2:SUITE H
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-4767
Mailing Address - Country:US
Mailing Address - Phone:763-441-1055
Mailing Address - Fax:763-441-7024
Practice Address - Street 1:19022 FREEPORT AVE NW
Practice Address - Street 2:SUITE H
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-4767
Practice Address - Country:US
Practice Address - Phone:763-441-1055
Practice Address - Fax:763-441-7024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN98-22038OtherMEDICA CLINIC NUMBER
MN115815OtherUCARE
MN52390HOOtherBCBS
MN379314100Medicaid
MN81961OtherHEALTH PARTNERS
MN96458OtherPREFERRED ONE
MN5C159ELOtherBCBS MATERIALS
MNCJ6982OtherRAILROAD MEDICARE
MN21-15856OtherMEDICA OPTICAL
MNCJ6982OtherRAILROAD MEDICARE
MNC03088Medicare PIN