Provider Demographics
NPI:1023283132
Name:OPTOMETRIC PHYSICIANS LLC
Entity type:Organization
Organization Name:OPTOMETRIC PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:LAMOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-385-8110
Mailing Address - Street 1:1411 ADAMS ST
Mailing Address - Street 2:APT 101
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:612-701-7064
Mailing Address - Fax:952-400-4207
Practice Address - Street 1:9300 E POINT DOUGLAS RD S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4030
Practice Address - Country:US
Practice Address - Phone:651-846-2836
Practice Address - Fax:952-400-4207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1893152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111460000Medicaid
MNC04901OtherMEDICARE PTAN
MNC04901OtherMEDICARE PTAN