Provider Demographics
NPI:1932327202
Name:MINNESOTA EYECARE NETWORK, INC.
Entity Type:Organization
Organization Name:MINNESOTA EYECARE NETWORK, INC.
Other - Org Name:NEITZKE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NEITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-631-1456
Mailing Address - Street 1:315 JEFFERSON ST S
Mailing Address - Street 2:PO BOX 146
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1533
Mailing Address - Country:US
Mailing Address - Phone:218-631-1456
Mailing Address - Fax:218-631-3213
Practice Address - Street 1:315 JEFFERSON ST S
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1533
Practice Address - Country:US
Practice Address - Phone:218-631-1456
Practice Address - Fax:218-631-3213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1932327202Medicare NSC