Provider Demographics
NPI:1558545582
Name:GORMAN OPTICAL INC
Entity Type:Organization
Organization Name:GORMAN OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CERTIFIED OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GORMAN MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:651-639-8227
Mailing Address - Street 1:2797 HAMLINE AVE NO
Mailing Address - Street 2:HAMLINE CENTER SUITE 2
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1715
Mailing Address - Country:US
Mailing Address - Phone:651-639-8227
Mailing Address - Fax:651-633-7010
Practice Address - Street 1:2797 HAMLINE AVE NO
Practice Address - Street 2:HAMLINE CENTER SUITE 2
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1715
Practice Address - Country:US
Practice Address - Phone:651-639-8227
Practice Address - Fax:651-633-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
072582156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1B06D56G0OtherBLUE CROSS B S