Provider Demographics
NPI:1609869031
Name:MOLACEK FAMILY EYECARE, INC.
Entity Type:Organization
Organization Name:MOLACEK FAMILY EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MOLACEK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-983-3434
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353-0218
Mailing Address - Country:US
Mailing Address - Phone:320-983-3434
Mailing Address - Fax:320-983-6280
Practice Address - Street 1:132 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1106
Practice Address - Country:US
Practice Address - Phone:320-983-3434
Practice Address - Fax:320-983-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160138500Medicaid
MNCO2736Medicare PIN
MN0149250001Medicare NSC