Provider Demographics
NPI:1245428135
Name:EYE Q OPTOMETRIC CLINIC, LIMITED
Entity Type:Organization
Organization Name:EYE Q OPTOMETRIC CLINIC, LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-326-9619
Mailing Address - Street 1:201 NW 4TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2753
Mailing Address - Country:US
Mailing Address - Phone:218-326-9619
Mailing Address - Fax:
Practice Address - Street 1:201 NW 4TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2753
Practice Address - Country:US
Practice Address - Phone:218-326-9619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2529332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU58324OtherRAILROAD MEDICARE
MN5C956EYOtherBLUE CROSS BLUE SHIELD
MN1245428135OtherRAILROAD MEDICARE
MNC04933OtherRAILROAD MEDICARE PTAN
MNC04933OtherMEDICARE PTAN
MN1190310001Medicare NSC
MN410001595Medicare PIN
MNC04933OtherMEDICARE PTAN