Provider Demographics
NPI:1477728418
Name:INDEX 53 OPT ICAL CO.INC.
Entity Type:Organization
Organization Name:INDEX 53 OPT ICAL CO.INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-252-9380
Mailing Address - Street 1:PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302
Mailing Address - Country:US
Mailing Address - Phone:320-252-9380
Mailing Address - Fax:320-654-9502
Practice Address - Street 1:306 MAIN ST E
Practice Address - Street 2:
Practice Address - City:ST STEPHEN
Practice Address - State:MN
Practice Address - Zip Code:56375
Practice Address - Country:US
Practice Address - Phone:320-252-9380
Practice Address - Fax:320-654-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0557730001Medicare NSC