Provider Demographics
NPI:1366863862
Name:PATIENT CENTERED EYE CARE OF MINNESOTA LLC
Entity Type:Organization
Organization Name:PATIENT CENTERED EYE CARE OF MINNESOTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ELAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:855-488-3937
Mailing Address - Street 1:3109 W 50TH ST
Mailing Address - Street 2:STE 124
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2102
Mailing Address - Country:US
Mailing Address - Phone:855-488-3937
Mailing Address - Fax:866-415-6805
Practice Address - Street 1:3109 W 50TH ST
Practice Address - Street 2:STE 124
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-2102
Practice Address - Country:US
Practice Address - Phone:855-488-3937
Practice Address - Fax:866-415-6805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3367152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH100126991Medicare PIN