Provider Demographics
NPI:1629148614
Name:ANNANDALE EYE CLINIC INC
Entity Type:Organization
Organization Name:ANNANDALE EYE CLINIC INC
Other - Org Name:ANNANDALE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TANCABEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-274-3701
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55302-0128
Mailing Address - Country:US
Mailing Address - Phone:320-274-3701
Mailing Address - Fax:320-274-3784
Practice Address - Street 1:500 ELM ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302
Practice Address - Country:US
Practice Address - Phone:320-274-3701
Practice Address - Fax:320-274-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN230R3TAOtherBCBS
MNT66196Medicare UPIN