Provider Demographics
NPI:1093888349
Name:ADVANCED VISION CLINIC AND OPTICAL LLC
Entity Type:Organization
Organization Name:ADVANCED VISION CLINIC AND OPTICAL LLC
Other - Org Name:ANGELA P JOHNSON LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:PORCH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-270-1621
Mailing Address - Street 1:1099 HELMO AVE N
Mailing Address - Street 2:SUITE 150
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6033
Mailing Address - Country:US
Mailing Address - Phone:651-739-3937
Mailing Address - Fax:651-739-9690
Practice Address - Street 1:1099 HELMO AVE N
Practice Address - Street 2:SUITE 150
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6033
Practice Address - Country:US
Practice Address - Phone:651-739-3937
Practice Address - Fax:651-739-9690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty