Provider Demographics
NPI:1508177890
Name:AVERA MARSHALL
Entity Type:Organization
Organization Name:AVERA MARSHALL
Other - Org Name:AVERA MEDICAL GROUP OPTOMETRY MOUNTAIN LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-537-9160
Mailing Address - Street 1:1040 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56159-1587
Mailing Address - Country:US
Mailing Address - Phone:507-427-2345
Mailing Address - Fax:
Practice Address - Street 1:1040 3RD AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKE
Practice Address - State:MN
Practice Address - Zip Code:56159-1587
Practice Address - Country:US
Practice Address - Phone:507-427-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152W00000X
207W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty