Provider Demographics
NPI:1366472342
Name:MAPLE GROVE VISION CLINIC, P.A.
Entity Type:Organization
Organization Name:MAPLE GROVE VISION CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:THIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-420-8030
Mailing Address - Street 1:13645 GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4405
Mailing Address - Country:US
Mailing Address - Phone:763-420-8030
Mailing Address - Fax:763-420-8342
Practice Address - Street 1:13645 GROVE DR
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4405
Practice Address - Country:US
Practice Address - Phone:763-420-8030
Practice Address - Fax:763-420-8342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN762603700Medicaid
MN5472200001Medicare NSC
MNC04001Medicare ID - Type Unspecified