Provider Demographics
NPI:1063550457
Name:CROOKSTON EYE CLINIC, P.C.
Entity type:Organization
Organization Name:CROOKSTON EYE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR OPTOMOTRIST
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-281-2020
Mailing Address - Street 1:216 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1939
Mailing Address - Country:US
Mailing Address - Phone:218-281-2020
Mailing Address - Fax:218-281-5997
Practice Address - Street 1:216 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1939
Practice Address - Country:US
Practice Address - Phone:218-281-2020
Practice Address - Fax:218-281-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2368152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN438992100Medicaid
MNC03189Medicare PIN
MN438992100Medicaid