Provider Demographics
NPI:1518059526
Name:ST CROIX VISION CENTER INC.
Entity Type:Organization
Organization Name:ST CROIX VISION CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-439-6400
Mailing Address - Street 1:13481 60TH ST N
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-1055
Mailing Address - Country:US
Mailing Address - Phone:651-439-6400
Mailing Address - Fax:651-439-6405
Practice Address - Street 1:13481 60TH ST N
Practice Address - Street 2:SUITE 200
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-1055
Practice Address - Country:US
Practice Address - Phone:651-439-6400
Practice Address - Fax:651-439-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD2763000152W00000X, 152WC0802X, 152WV0400X
LD2763000152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN108J4JOOtherBLUE CROSS BLUE SHEILD GR
MN904623200Medicaid
MN904623200Medicaid
MN410001714Medicare ID - Type UnspecifiedWPS MEDICARE NUMBER