Provider Demographics
NPI:1124179049
Name:DJ-MN INC
Entity Type:Organization
Organization Name:DJ-MN INC
Other - Org Name:SELECT EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-427-4000
Mailing Address - Street 1:1920 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2437
Mailing Address - Country:US
Mailing Address - Phone:763-427-4000
Mailing Address - Fax:
Practice Address - Street 1:527 STATE HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8662
Practice Address - Country:US
Practice Address - Phone:763-427-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04598Medicare PIN
6010210002Medicare NSC