Provider Demographics
NPI:1346322609
Name:MANKATO OPTICAL INC
Entity Type:Organization
Organization Name:MANKATO OPTICAL INC
Other - Org Name:EYE Q VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIESLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-387-6695
Mailing Address - Street 1:1400 MADISON AVE
Mailing Address - Street 2:SUITE 338
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-387-6695
Mailing Address - Fax:507-387-6696
Practice Address - Street 1:1400 MADISON AVE
Practice Address - Street 2:SUITE 338
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-387-6695
Practice Address - Fax:507-387-6696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANKATO OPTICAL INC DBA EYE Q VISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN630938100Medicaid
MN630938100Medicaid
MN1305680002Medicare NSC