Provider Demographics
NPI:1972657658
Name:ST PETER EYECARE CENTER, INC
Entity Type:Organization
Organization Name:ST PETER EYECARE CENTER, INC
Other - Org Name:LECENTER EYECARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DIRKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-931-6436
Mailing Address - Street 1:320 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-1352
Mailing Address - Country:US
Mailing Address - Phone:507-931-6436
Mailing Address - Fax:507-934-9625
Practice Address - Street 1:1 E MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:LE CENTER
Practice Address - State:MN
Practice Address - Zip Code:56057-1501
Practice Address - Country:US
Practice Address - Phone:507-357-6665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST PETER EYECARE CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-22
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2076152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0322460001OtherDMERC
MN15568OtherHEALTH PARTNERS
MN33077DIOtherBLUE CROSS BLUE SHIELD
MN44977THOtherBLUEPLUS EYEWEAR
MN114338OtherUCARE
MN2200871OtherMEDICA
MN706140400Medicaid
MNC06707OtherMEDICARE
MN44977THOtherBLUEPLUS EYEWEAR