Provider Demographics
NPI:1407162589
Name:PENNY P VIZINA OD LLC
Entity type:Organization
Organization Name:PENNY P VIZINA OD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:PETERSON
Authorized Official - Last Name:VIZINA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-451-5800
Mailing Address - Street 1:121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2970
Mailing Address - Country:US
Mailing Address - Phone:507-451-5800
Mailing Address - Fax:
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2970
Practice Address - Country:US
Practice Address - Phone:507-451-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2381152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0776480Medicaid
MN410003463OtherMEDICARE PROVIDER NUMBER
MN6601720001Medicare NSC