Provider Demographics
NPI:1720059421
Name:MINNESOTA EYE LASER & SURGERY CENTERS, LLC
Entity Type:Organization
Organization Name:MINNESOTA EYE LASER & SURGERY CENTERS, LLC
Other - Org Name:MINNESOTA EYE LASER & SURGERY CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-270-6658
Mailing Address - Street 1:9801 DUPONT AVE S
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3100
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:952-567-6156
Practice Address - Street 1:9801 DUPONT AVE S
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3100
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:952-567-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327379261QA1903X
261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN034216600Medicaid
MN24D0893659OtherCLIA
MNP00296022OtherRR MEDICARE
MN490000063Medicare PIN