Provider Demographics
NPI:1295887883
Name:REAL EYES LLC
Entity type:Organization
Organization Name:REAL EYES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-933-3722
Mailing Address - Street 1:8332 HIGHWAY 7
Mailing Address - Street 2:KNOLLWOOD MALL
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3991
Mailing Address - Country:US
Mailing Address - Phone:952-933-3722
Mailing Address - Fax:952-933-6578
Practice Address - Street 1:8332 HIGHWAY 7
Practice Address - Street 2:KNOLLWOOD MALL
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3991
Practice Address - Country:US
Practice Address - Phone:952-933-3722
Practice Address - Fax:952-933-6578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0626900006OtherMEDICARE DMERC REGION B
MN669479900Medicaid
MN21-28989OtherMEDICA-UHC
MN21B67PEOtherBCBS DR
MN20B03PEOtherBCBS STORE
MNC05046OtherMEDICARE PART B WPS