Provider Demographics
NPI:1902932965
Name:RIVER LAKE CLINIC LLC
Entity type:Organization
Organization Name:RIVER LAKE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANEN-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:O D, M S
Authorized Official - Phone:612-722-1003
Mailing Address - Street 1:4323 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2307
Mailing Address - Country:US
Mailing Address - Phone:612-722-1003
Mailing Address - Fax:612-721-6336
Practice Address - Street 1:4323 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2307
Practice Address - Country:US
Practice Address - Phone:612-722-1003
Practice Address - Fax:612-721-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1652152WX0102X, 152WV0400X, 152W00000X
MN3331152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X
MNLP2754103T00000X, 103TF0000X, 103TC1900X, 103TA0700X, 103TB0200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR48949Medicare UPIN
MNT39578Medicare UPIN
MN410003787Medicare PIN