Provider Demographics
NPI:1629137419
Name:BLUSTIN OPTICAL CENTER DBA DERIN J VAN LOON, O.D.
Entity Type:Organization
Organization Name:BLUSTIN OPTICAL CENTER DBA DERIN J VAN LOON, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-834-8070
Mailing Address - Street 1:802 11TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1413
Mailing Address - Country:US
Mailing Address - Phone:218-834-8070
Mailing Address - Fax:
Practice Address - Street 1:802 11TH ST
Practice Address - Street 2:STE A
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1413
Practice Address - Country:US
Practice Address - Phone:218-834-8070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122437OtherU CARE
MN74123BLOtherBCBS OF MN
MN5506010002OtherDMERC
MN2122765OtherMEDICA