Provider Demographics
NPI:1265734909
Name:VALLEY EYE CLINIC & OPTICAL, PA
Entity type:Organization
Organization Name:VALLEY EYE CLINIC & OPTICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:612-486-1749
Mailing Address - Street 1:1431 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1064
Mailing Address - Country:US
Mailing Address - Phone:612-486-1749
Mailing Address - Fax:612-486-1750
Practice Address - Street 1:1431 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1064
Practice Address - Country:US
Practice Address - Phone:612-486-1749
Practice Address - Fax:612-486-1750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2776OtherLICENSE
MN=========OtherTAX ID
MN=========OtherTAX ID