Provider Demographics
NPI:1861675290
Name:OPTOMETRIC VISION SERVICES PA
Entity Type:Organization
Organization Name:OPTOMETRIC VISION SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:MACIK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-913-7520
Mailing Address - Street 1:150 E TRAVELERS TRL
Mailing Address - Street 2:SUITE D
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7000 YORK AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4213
Practice Address - Country:US
Practice Address - Phone:952-922-8118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty