Provider Demographics
NPI:1821243239
Name:FIFTH AVENUE OF EDINA INC.
Entity Type:Organization
Organization Name:FIFTH AVENUE OF EDINA INC.
Other - Org Name:FIFTH AVENUE OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-922-1052
Mailing Address - Street 1:3540 GALLERIA
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4218
Mailing Address - Country:US
Mailing Address - Phone:952-922-1052
Mailing Address - Fax:952-922-2518
Practice Address - Street 1:3540 GALLERIA
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4218
Practice Address - Country:US
Practice Address - Phone:952-922-1052
Practice Address - Fax:952-922-2518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1456152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C05969Medicare PIN
MN0480220001Medicare NSC