Provider Demographics
NPI:1700263985
Name:MOOSE LAKE EYE CARE, LLC
Entity Type:Organization
Organization Name:MOOSE LAKE EYE CARE, LLC
Other - Org Name:NORTHERN MINNESOTA EYE CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:N
Authorized Official - Last Name:NARAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-485-8495
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:HINCKLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55037-0728
Mailing Address - Country:US
Mailing Address - Phone:320-384-6361
Mailing Address - Fax:320-384-6361
Practice Address - Street 1:45 LADY LUCK DR.
Practice Address - Street 2:SUITE 120
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037
Practice Address - Country:US
Practice Address - Phone:320-384-6361
Practice Address - Fax:320-384-6361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOOSE LAKE EYE CARE, LLC D/B/A NORTHERN MINNESOTA EYE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1235188079OtherPROVIDER NPI
MN1411674742Medicaid
MN1760558399OtherPROVIDER NPI
MN1275582421OtherPROVIDER NPI
MN1411674742Medicaid