Provider Demographics
NPI:1184095671
Name:WASECA OPTOMETRIC CENTER
Entity type:Organization
Organization Name:WASECA OPTOMETRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:GUTFLEISCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-835-2020
Mailing Address - Street 1:1111 2ND ST NE
Mailing Address - Street 2:PO BOX 464
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-2416
Mailing Address - Country:US
Mailing Address - Phone:507-835-2020
Mailing Address - Fax:507-833-7677
Practice Address - Street 1:1111 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093-2416
Practice Address - Country:US
Practice Address - Phone:507-835-2020
Practice Address - Fax:507-833-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty