Provider Demographics
NPI:1376713966
Name:CAPITAL FAMILY EYE CLINIC LLC
Entity Type:Organization
Organization Name:CAPITAL FAMILY EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SE
Authorized Official - Middle Name:CECELIA
Authorized Official - Last Name:XIONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-738-5755
Mailing Address - Street 1:6332 HIGHLAND HILLS BLVD S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4478
Mailing Address - Country:US
Mailing Address - Phone:608-738-5755
Mailing Address - Fax:
Practice Address - Street 1:941 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4003
Practice Address - Country:US
Practice Address - Phone:608-738-5755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3001152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty