Provider Demographics
NPI:1194973354
Name:CLOQUET EYECARE AND CONTACT LENS CENTER
Entity type:Organization
Organization Name:CLOQUET EYECARE AND CONTACT LENS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:REEDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-879-2400
Mailing Address - Street 1:807 CLOQUET AVE
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1675
Mailing Address - Country:US
Mailing Address - Phone:218-879-2400
Mailing Address - Fax:
Practice Address - Street 1:807 CLOQUET AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1675
Practice Address - Country:US
Practice Address - Phone:218-879-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT63074OtherUPIN
MN042338600Medicaid
MN4654070001Medicare NSC
MN042338600Medicaid