Provider Demographics
NPI:1932268257
Name:LE SUEUR EYECARE CENTER LLC
Entity Type:Organization
Organization Name:LE SUEUR EYECARE CENTER LLC
Other - Org Name:MOOTZ EYE CLINIC PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:DIRKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-469-9715
Mailing Address - Street 1:101 MAIN ST S STE 103105
Mailing Address - Street 2:
Mailing Address - City:LE SUEUR
Mailing Address - State:MN
Mailing Address - Zip Code:56058-7502
Mailing Address - Country:US
Mailing Address - Phone:507-665-3366
Mailing Address - Fax:507-665-3990
Practice Address - Street 1:101 MAIN ST S STE 103
Practice Address - Street 2:
Practice Address - City:LE SUEUR
Practice Address - State:MN
Practice Address - Zip Code:56058-7503
Practice Address - Country:US
Practice Address - Phone:507-665-3366
Practice Address - Fax:507-665-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN193518600Medicaid