Provider Demographics
NPI:1952309122
Name:GERRY'S VISION SHOPPE, INC
Entity Type:Organization
Organization Name:GERRY'S VISION SHOPPE, INC
Other - Org Name:GERRY'S VISION SHOPPE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KLOCKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-864-6111
Mailing Address - Street 1:1234 GREELEY AVE N
Mailing Address - Street 2:PO BOX 186
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-2103
Mailing Address - Country:US
Mailing Address - Phone:320-864-6111
Mailing Address - Fax:320-864-6134
Practice Address - Street 1:1234 GREELEY AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2103
Practice Address - Country:US
Practice Address - Phone:320-864-6111
Practice Address - Fax:320-864-6134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Not Answered332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
964661001450OtherPREFERRED ONE
16062GEOtherBCBS
21-18815OtherMEDICA
21-18815OtherMEDICA
1301220002Medicare ID - Type Unspecified