Provider Demographics
NPI:1255652137
Name:MILLE LACS FAMILY EYE CARE
Entity Type:Organization
Organization Name:MILLE LACS FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HONSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-495-3500
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:WAHKON
Mailing Address - State:MN
Mailing Address - Zip Code:56386-0039
Mailing Address - Country:US
Mailing Address - Phone:320-495-3500
Mailing Address - Fax:320-495-3502
Practice Address - Street 1:270 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WAHKON
Practice Address - State:MN
Practice Address - Zip Code:56386-4401
Practice Address - Country:US
Practice Address - Phone:320-495-3500
Practice Address - Fax:320-495-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1760709125Medicaid