Provider Demographics
NPI:1720167273
Name:NICHOLAS VINCELLI OPTOMETRY, INC.
Entity Type:Organization
Organization Name:NICHOLAS VINCELLI OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:VINCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-220-4849
Mailing Address - Street 1:2095 HARBOUR OAK DR SE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-6614
Mailing Address - Country:US
Mailing Address - Phone:773-220-4849
Mailing Address - Fax:
Practice Address - Street 1:1881 E MADISON AVE
Practice Address - Street 2:WAL-MART VISION CENTER STORE #1473
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6200
Practice Address - Country:US
Practice Address - Phone:507-388-9805
Practice Address - Fax:507-388-9812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty