Provider Demographics
NPI:1104855287
Name:EYECARE CENTERS OF AITKIN & MCGREGOR OPTOMETRISTS, PA
Entity Type:Organization
Organization Name:EYECARE CENTERS OF AITKIN & MCGREGOR OPTOMETRISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KINZER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-927-3213
Mailing Address - Street 1:312 MINNESOTA AVE N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431
Mailing Address - Country:US
Mailing Address - Phone:218-927-3213
Mailing Address - Fax:218-927-2266
Practice Address - Street 1:312 MINNESOTA AVE. N
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1414
Practice Address - Country:US
Practice Address - Phone:218-927-3213
Practice Address - Fax:218-927-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2588152W00000X
MN1998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN601218300Medicaid
MN601218300Medicaid