Provider Demographics
NPI:1972663383
Name:ANDOVER OPTICAL INC
Entity Type:Organization
Organization Name:ANDOVER OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRES
Authorized Official - Prefix:MS
Authorized Official - First Name:LAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-421-0141
Mailing Address - Street 1:13855 ROUND LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3664
Mailing Address - Country:US
Mailing Address - Phone:763-421-0141
Mailing Address - Fax:763-421-0334
Practice Address - Street 1:13855 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3664
Practice Address - Country:US
Practice Address - Phone:763-421-0141
Practice Address - Fax:763-421-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16125OtherHEALTH PARTNERS
MN114915OtherUCARE
MN747001OtherPREFERREDONE
MN2115818OtherMEDICA
MN10294ANOtherBCBS
MN06954600Medicare ID - Type Unspecified