Provider Demographics
NPI:1174688725
Name:KALLEVIG, GLENN ORVILLE (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ORVILLE
Last Name:KALLEVIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14940 47TH ST NE
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56329-4621
Mailing Address - Country:US
Mailing Address - Phone:320-968-8091
Mailing Address - Fax:
Practice Address - Street 1:101 S RUM RIVER DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1815
Practice Address - Country:US
Practice Address - Phone:763-389-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU32791Medicare UPIN