Provider Demographics
NPI:1760089700
Name:EAGAN EYE CLINIC LLC
Entity Type:Organization
Organization Name:EAGAN EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHUDNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-370-5552
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:
Practice Address - Street 1:206 DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1331
Practice Address - Country:US
Practice Address - Phone:320-235-0365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGAN EYE CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty