Provider Demographics
NPI:1689882268
Name:OPTOMETRIC ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:OPTOMETRIC ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-944-3131
Mailing Address - Street 1:12577 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1938
Mailing Address - Country:US
Mailing Address - Phone:952-944-3131
Mailing Address - Fax:952-944-9675
Practice Address - Street 1:2024 EDEN PRAIRIE CTR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-6035
Practice Address - Country:US
Practice Address - Phone:952-944-3131
Practice Address - Fax:952-944-9675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTOMETRIC ASSOCIATES, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-18
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1H401OPOtherBLUE CROSS BLUE SHIELD MN
MN31855OtherHEALTH PARTNERS
MNC03536Medicare ID - Type Unspecified