Provider Demographics
NPI:1306042817
Name:NORTH SUBURBAN OPTICAL
Entity type:Organization
Organization Name:NORTH SUBURBAN OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOBANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-421-7420
Mailing Address - Street 1:3777 COON RAPIDS BLVD NW # 100
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2630
Mailing Address - Country:US
Mailing Address - Phone:763-421-8524
Mailing Address - Fax:763-421-0730
Practice Address - Street 1:11855 ULYSSES ST
Practice Address - Street 2:SUITE 140
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434
Practice Address - Country:US
Practice Address - Phone:763-421-7420
Practice Address - Fax:763-421-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1157570002Medicare NSC