Provider Demographics
NPI:1629254867
Name:MELICHER, P.C.
Entity Type:Organization
Organization Name:MELICHER, P.C.
Other - Org Name:ADVANCED OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MELICHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-744-3288
Mailing Address - Street 1:4369 OLAUGHLIN DR
Mailing Address - Street 2:
Mailing Address - City:EVELETH
Mailing Address - State:MN
Mailing Address - Zip Code:55734-4029
Mailing Address - Country:US
Mailing Address - Phone:218-744-3288
Mailing Address - Fax:
Practice Address - Street 1:5465 MOUNTAIN IRON DR
Practice Address - Street 2:SUITE 700
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-3372
Practice Address - Country:US
Practice Address - Phone:218-741-3000
Practice Address - Fax:218-741-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 2409152W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03692Medicare PIN