Provider Demographics
NPI:1972773422
Name:PROFESSIONAL VISION CARE, PA
Entity type:Organization
Organization Name:PROFESSIONAL VISION CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:QUY
Authorized Official - Middle Name:T
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-807-4173
Mailing Address - Street 1:1409 131ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 131ST AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4108
Practice Address - Country:US
Practice Address - Phone:952-807-4173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNV052998Medicare UPIN