Provider Demographics
NPI:1750502597
Name:XUAN-MAI TA INC.OPTOMETRIST AND ASSOCIATES
Entity Type:Organization
Organization Name:XUAN-MAI TA INC.OPTOMETRIST AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:XUANMAI
Authorized Official - Middle Name:THI
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-380-8068
Mailing Address - Street 1:12167 CARTWAY CURVE
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347
Mailing Address - Country:US
Mailing Address - Phone:952-380-8068
Mailing Address - Fax:
Practice Address - Street 1:2718 NICOLLET AVENUE SOUTH
Practice Address - Street 2:SUITE 103
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408
Practice Address - Country:US
Practice Address - Phone:612-871-1518
Practice Address - Fax:612-871-2585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT2107152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04592Medicare PIN
MNT97995Medicare UPIN