Provider Demographics
NPI:1841221785
Name:HOMETOWN EYE CARE, INC
Entity Type:Organization
Organization Name:HOMETOWN EYE CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SEALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-263-8444
Mailing Address - Street 1:621 ROSE DR
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-4653
Mailing Address - Country:US
Mailing Address - Phone:763-263-8444
Mailing Address - Fax:763-263-8583
Practice Address - Street 1:621 ROSE DR
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4653
Practice Address - Country:US
Practice Address - Phone:763-263-8444
Practice Address - Fax:763-263-8583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN812523600Medicaid
MN0746580001Medicare NSC
MN812523600Medicaid