Provider Demographics
NPI:1629591490
Name:MONTICELLO OPTICAL CENTER INC.
Entity Type:Organization
Organization Name:MONTICELLO OPTICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CAVANAGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-636-2020
Mailing Address - Street 1:2655 INNSBRUCK DR STE B
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-9304
Mailing Address - Country:US
Mailing Address - Phone:651-636-2020
Mailing Address - Fax:
Practice Address - Street 1:261 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-9317
Practice Address - Country:US
Practice Address - Phone:763-295-5292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty