Provider Demographics
NPI:1376652420
Name:SAUK CENTRE EYE CLINIC P.A.
Entity Type:Organization
Organization Name:SAUK CENTRE EYE CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-352-3026
Mailing Address - Street 1:324 MAIN ST S STE 101
Mailing Address - Street 2:
Mailing Address - City:SAUK CENTRE
Mailing Address - State:MN
Mailing Address - Zip Code:56378-1349
Mailing Address - Country:US
Mailing Address - Phone:320-352-3026
Mailing Address - Fax:320-352-1164
Practice Address - Street 1:324 MAIN ST S STE 101
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378-1349
Practice Address - Country:US
Practice Address - Phone:320-352-3026
Practice Address - Fax:320-352-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00063212Medicare PIN
MN0460960001Medicare NSC