Provider Demographics
NPI:1972528776
Name:MICKELSON EYE CLINIC, PA
Entity Type:Organization
Organization Name:MICKELSON EYE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:R
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-683-3937
Mailing Address - Street 1:126 LABREE AVE S
Mailing Address - Street 2:PO BOX 521
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2819
Mailing Address - Country:US
Mailing Address - Phone:218-683-3937
Mailing Address - Fax:218-683-4557
Practice Address - Street 1:126 LABREE AVE S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2819
Practice Address - Country:US
Practice Address - Phone:218-683-3937
Practice Address - Fax:218-683-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1026440OtherPREFERRED ONE
MN2201140OtherMEDICA
MN71973OtherHEALTH PARTNERS
MN140661OtherUCARE
MN61B37MIOtherBLUE CROSS BLUE SHIELD
MN3902360001Medicare NSC
MN2201140OtherMEDICA
MNCH5041Medicare PIN
MNT65864Medicare UPIN