Provider Demographics
NPI:1437332939
Name:DJ-MN, INC
Entity Type:Organization
Organization Name:DJ-MN, INC
Other - Org Name:INNOVATIVE EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-427-4000
Mailing Address - Street 1:1700 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1930
Mailing Address - Country:US
Mailing Address - Phone:763-684-0025
Mailing Address - Fax:763-684-0847
Practice Address - Street 1:1700 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1930
Practice Address - Country:US
Practice Address - Phone:763-684-0025
Practice Address - Fax:763-684-0847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN21-00484OtherMEDICA
MN454103200Medicaid
MN14B51INOtherBLUECROSSBLUESHIELD
MN21-00484OtherMEDICA