Provider Demographics
NPI:1518959121
Name:OPHTHALMOLOGY ASSOCIATES OF MANKATO PA
Entity Type:Organization
Organization Name:OPHTHALMOLOGY ASSOCIATES OF MANKATO PA
Other - Org Name:20/20 OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDI
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-625-2020
Mailing Address - Street 1:1630 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4801
Mailing Address - Country:US
Mailing Address - Phone:507-625-2020
Mailing Address - Fax:507-388-9962
Practice Address - Street 1:1630 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4801
Practice Address - Country:US
Practice Address - Phone:507-625-2020
Practice Address - Fax:507-388-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332B00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0446990002Medicare NSC