Provider Demographics
NPI:1407150485
Name:ELBOW LAKE EYE CARE CENTER
Entity Type:Organization
Organization Name:ELBOW LAKE EYE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF SERVICES COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-736-8477
Mailing Address - Street 1:930 1ST ST NE # 101
Mailing Address - Street 2:
Mailing Address - City:ELBOW LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56531-4611
Mailing Address - Country:US
Mailing Address - Phone:218-685-4341
Mailing Address - Fax:
Practice Address - Street 1:930 1ST ST NE # 101
Practice Address - Street 2:
Practice Address - City:ELBOW LAKE
Practice Address - State:MN
Practice Address - Zip Code:56531-4611
Practice Address - Country:US
Practice Address - Phone:218-685-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE REGION HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty