Provider Demographics
NPI:1326591603
Name:EYE CLINIC NORTH, PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:EYE CLINIC NORTH, PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SIPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-741-5886
Mailing Address - Street 1:413 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2525
Mailing Address - Country:US
Mailing Address - Phone:218-741-5886
Mailing Address - Fax:218-741-5894
Practice Address - Street 1:2016 1ST AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1728
Practice Address - Country:US
Practice Address - Phone:218-263-3633
Practice Address - Fax:218-263-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH300137520Medicare UPIN