Provider Demographics
NPI:1508267543
Name:MSP FAMILY EYE CLINIC, LLC
Entity Type:Organization
Organization Name:MSP FAMILY EYE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:KOSTECKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-401-9202
Mailing Address - Street 1:4848 COUNTY ROAD 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2635
Mailing Address - Country:US
Mailing Address - Phone:952-401-9202
Mailing Address - Fax:
Practice Address - Street 1:4848 COUNTY ROAD 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2635
Practice Address - Country:US
Practice Address - Phone:952-401-9202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty