Provider Demographics
NPI:1265647416
Name:PROGRESSIVE EYECARE ASSOCIATES
Entity Type:Organization
Organization Name:PROGRESSIVE EYECARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-645-3997
Mailing Address - Street 1:1690 UNIVERSITY AVE WEST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-645-3997
Mailing Address - Fax:651-641-7207
Practice Address - Street 1:14655 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124
Practice Address - Country:US
Practice Address - Phone:651-645-3997
Practice Address - Fax:651-641-7207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN776207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS0820OtherRAILROAD MEDICARE
0461340002OtherDMERC
C01207Medicare ID - Type Unspecified