Provider Demographics
NPI:1245356914
Name:GLACIAL RIDGE EYE CLINIC, INC.
Entity type:Organization
Organization Name:GLACIAL RIDGE EYE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEJONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-634-4516
Mailing Address - Street 1:24 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1619
Mailing Address - Country:US
Mailing Address - Phone:320-634-4516
Mailing Address - Fax:
Practice Address - Street 1:24 1ST ST SE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1619
Practice Address - Country:US
Practice Address - Phone:320-634-4516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2027152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT65451Medicare UPIN
MNC03634Medicare PIN
MNU10095Medicare UPIN