Provider Demographics
NPI:1932266111
Name:CORNERSTONE VISION CLINIC LLC
Entity Type:Organization
Organization Name:CORNERSTONE VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-493-3937
Mailing Address - Street 1:1 CENTRAL AVE W
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4591
Mailing Address - Country:US
Mailing Address - Phone:763-493-3937
Mailing Address - Fax:763-315-3834
Practice Address - Street 1:1 CENTRAL AVE W
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4591
Practice Address - Country:US
Practice Address - Phone:763-493-3937
Practice Address - Fax:763-315-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2203583OtherMEDICA
MN422K5COOtherBCBS
MN422K5COOtherBCBS