Provider Demographics
NPI:1083737159
Name:SOUTHWEST EYE CARE
Entity Type:Organization
Organization Name:SOUTHWEST EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:NARUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-466-3937
Mailing Address - Street 1:1464 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2525
Mailing Address - Country:US
Mailing Address - Phone:952-466-3937
Mailing Address - Fax:952-466-3936
Practice Address - Street 1:304 W HIGHWAY 212
Practice Address - Street 2:
Practice Address - City:NORWOOD YOUNG AMERICA
Practice Address - State:MN
Practice Address - Zip Code:55368-9775
Practice Address - Country:US
Practice Address - Phone:952-467-2250
Practice Address - Fax:952-467-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2627152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650127300Medicaid
MN1104975762OtherNPI CHAD DOCKTER
MN1922004514OtherNPI GREGORY MACIK
MN617518000Medicaid
MN1770631889OtherNPI CHRISTOPHER FREED
MN683719100Medicaid
MN1881741213OtherAMY FREED
MN958906600Medicaid
MN650127300Medicaid
MN1770631889OtherNPI CHRISTOPHER FREED
MN1881741213OtherAMY FREED
MN410002757Medicare ID - Type UnspecifiedGREGORY MACIK
MN617518000Medicaid
MNU68764Medicare UPIN
MNU82414Medicare UPIN
MN958906600Medicaid