Provider Demographics
NPI:1821129263
Name:MANKATO VISION CENTER LLC
Entity Type:Organization
Organization Name:MANKATO VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TASLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-387-4227
Mailing Address - Street 1:1819 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4841
Mailing Address - Country:US
Mailing Address - Phone:507-387-4227
Mailing Address - Fax:507-345-7156
Practice Address - Street 1:1819 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4841
Practice Address - Country:US
Practice Address - Phone:507-387-4227
Practice Address - Fax:507-345-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6424033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03492Medicare PIN
MN5553960001Medicare NSC