Provider Demographics
NPI:1215014378
Name:EYEWEAR SPECIALISTS
Entity Type:Organization
Organization Name:EYEWEAR SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-832-8100
Mailing Address - Street 1:7450 FRANCE AVE S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4787
Mailing Address - Country:US
Mailing Address - Phone:952-832-8120
Mailing Address - Fax:952-832-8124
Practice Address - Street 1:4201 DEAN LAKES BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2829
Practice Address - Country:US
Practice Address - Phone:952-445-5763
Practice Address - Fax:952-233-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4699580332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN21-27952OtherMEDICA
MN51083CLOtherBCBS
MN6944973-00Medicaid
MN6944973-00Medicaid