Provider Demographics
NPI:1881136216
Name:ST,. STEPHEN OPTICAL
Entity type:Organization
Organization Name:ST,. STEPHEN OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:ANTON
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-252-9380
Mailing Address - Street 1:306 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHEN
Mailing Address - State:MN
Mailing Address - Zip Code:56375-4601
Mailing Address - Country:US
Mailing Address - Phone:320-252-9380
Mailing Address - Fax:320-654-9502
Practice Address - Street 1:306 MAIN ST E
Practice Address - Street 2:
Practice Address - City:SAINT STEPHEN
Practice Address - State:MN
Practice Address - Zip Code:56375-4601
Practice Address - Country:US
Practice Address - Phone:320-252-9380
Practice Address - Fax:320-654-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier