Provider Demographics
NPI:1326133497
Name:THEOBALD FAMILY EYE CARE, LLP
Entity Type:Organization
Organization Name:THEOBALD FAMILY EYE CARE, LLP
Other - Org Name:THEOBALD FAMILY EYE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:THEOBALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-624-2095
Mailing Address - Street 1:3308 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4000
Mailing Address - Country:US
Mailing Address - Phone:218-727-6400
Mailing Address - Fax:218-464-4277
Practice Address - Street 1:416 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2548
Practice Address - Country:US
Practice Address - Phone:218-624-2095
Practice Address - Fax:218-624-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCB6890OtherRAILROAD MEDICARE
MN6C246THOtherBCBS & FIRST PLAN
MN402964000Medicaid
MN402964000Medicaid
MN402964000Medicaid
MNCB6890OtherRAILROAD MEDICARE