Provider Demographics
NPI:1538131131
Name:MINNEAPOLIS OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:MINNEAPOLIS OPHTHALMOLOGY ASC LLC
Other - Org Name:MINNEAPOLIS EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:8401 GOLDEN VALLEY RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4486
Mailing Address - Country:US
Mailing Address - Phone:763-383-4150
Mailing Address - Fax:763-383-4151
Practice Address - Street 1:8401 GOLDEN VALLEY RD
Practice Address - Street 2:SUITE 340
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4486
Practice Address - Country:US
Practice Address - Phone:763-383-4150
Practice Address - Fax:763-383-4151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN320515261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0015008-00Medicaid
MN=========OtherTRIWEST HEALTHCARE ALLIAN
MN=========OtherTRIWEST HEALTHCARE ALLIAN
MN0015008-00Medicaid
MN490004661Medicare PIN