Provider Demographics
NPI:1700163540
Name:OMNI VISION & LEARNING CENTER
Entity Type:Organization
Organization Name:OMNI VISION & LEARNING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-314-0664
Mailing Address - Street 1:9766 FALLON AVE NE STE 105
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-4589
Mailing Address - Country:US
Mailing Address - Phone:763-314-0664
Mailing Address - Fax:763-314-0665
Practice Address - Street 1:9766 FALLON AVE NE STE 105
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4589
Practice Address - Country:US
Practice Address - Phone:763-314-0664
Practice Address - Fax:763-314-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2734152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty