Provider Demographics
NPI:1447386552
Name:OLDE WORLD OPTICAL LTD
Entity Type:Organization
Organization Name:OLDE WORLD OPTICAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-835-1775
Mailing Address - Street 1:117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011-1821
Mailing Address - Country:US
Mailing Address - Phone:952-873-2244
Mailing Address - Fax:952-873-2244
Practice Address - Street 1:117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011-1821
Practice Address - Country:US
Practice Address - Phone:952-873-2244
Practice Address - Fax:952-873-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1900152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0222370001Medicare NSC