Provider Demographics
NPI:1093891624
Name:KA BLOOMQUIST RG BAKEWELL OD PA
Entity Type:Organization
Organization Name:KA BLOOMQUIST RG BAKEWELL OD PA
Other - Org Name:EYE ASSOCIATES OF ALEXANDRIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-763-4321
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:120 12TH AVE E
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-763-4321
Mailing Address - Fax:320-763-6921
Practice Address - Street 1:120 12TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-763-4321
Practice Address - Fax:320-763-6921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
030701053OtherPRIMEWEST
96477OtherPREFERRED ONE
942812700OtherMEDICAL ASSISTANCE
121754OtherU CARE
4C196BLOtherBLUE CROSS
CG3570OtherRR MEDICARE
61045BLOtherBLUE CROSS
0373300001OtherDME
5982OtherHEALTH PARTNERS
2115931OtherMEDICA
MNC07815Medicare PIN