Provider Demographics
NPI:1285084954
Name:NORTH SUBURBAN OPTICAL
Entity type:Organization
Organization Name:NORTH SUBURBAN OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORGANIZATIONAL LIAISON
Authorized Official - Prefix:
Authorized Official - First Name:DELTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-592-8413
Mailing Address - Street 1:3777 COON RAPIDS BLVD NW
Mailing Address - Street 2:STE 100
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2630
Mailing Address - Country:US
Mailing Address - Phone:763-421-7420
Mailing Address - Fax:
Practice Address - Street 1:4520 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-3602
Practice Address - Country:US
Practice Address - Phone:763-421-7420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC00856Medicare UPIN