Provider Demographics
NPI:1851585822
Name:GIBBONS OPTICAL, LLC
Entity Type:Organization
Organization Name:GIBBONS OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BJORNGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-288-6964
Mailing Address - Street 1:150 17TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0321
Mailing Address - Country:US
Mailing Address - Phone:507-288-6964
Mailing Address - Fax:507-252-5307
Practice Address - Street 1:150 17TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0321
Practice Address - Country:US
Practice Address - Phone:507-288-6964
Practice Address - Fax:507-252-5307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2343332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN691325300Medicaid
U30915Medicare UPIN
5036650001Medicare NSC