Provider Demographics
NPI:1407960651
Name:MINNESOTA EYECARE NETWORK, INC
Entity Type:Organization
Organization Name:MINNESOTA EYECARE NETWORK, INC
Other - Org Name:AZURE VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NEITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-346-3310
Mailing Address - Street 1:652 JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-2307
Mailing Address - Country:US
Mailing Address - Phone:218-631-1456
Mailing Address - Fax:218-631-3213
Practice Address - Street 1:340 FOX STREET
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1733
Practice Address - Country:US
Practice Address - Phone:218-346-3310
Practice Address - Fax:218-346-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN299206000Medicaid
MNC02078Medicare ID - Type Unspecified
MN0316210002Medicare NSC