Provider Demographics
NPI:1891183430
Name:BETTY'S MOBILE OPTICAL, LLC
Entity Type:Organization
Organization Name:BETTY'S MOBILE OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:LEERVIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-688-3486
Mailing Address - Street 1:1001 CLIFF RD E STE 301
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1541
Mailing Address - Country:US
Mailing Address - Phone:651-688-3486
Mailing Address - Fax:
Practice Address - Street 1:1001 CLIFF RD E STE 301
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-1541
Practice Address - Country:US
Practice Address - Phone:651-688-3486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN759560400029332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier