Provider Demographics
NPI:1194377671
Name:WALLERICH EYE CARE LLC
Entity Type:Organization
Organization Name:WALLERICH EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WALLERICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:612-643-3525
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0747
Mailing Address - Country:US
Mailing Address - Phone:763-746-2094
Mailing Address - Fax:
Practice Address - Street 1:1300 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4103
Practice Address - Country:US
Practice Address - Phone:612-643-3525
Practice Address - Fax:612-299-1452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881135093Medicaid