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Contact Information

NORTHWEST EYE CLINIC, LLC
12000 ELM CREEK BLVD N STE 100
MAPLE GROVE, MN55369-7074
 Phone: 763-416-7600
 Fax: 763-416-7634
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

Ophthalmology

207W00000X 18 Physician/Ophthalmology
Indicates primary specialty

NPI Profile & details for NORTHWEST EYE CLINIC, LLC

NPI Number 1164508917
LBN Legal business name NORTHWEST EYE CLINIC, LLC
Authorized official KELLY PETTENGILL - (CREDENTIALING AND DATA MANAGEMENT)
Entity Organization
Organization subpart 1 No
Enumeration date 10/27/2006
Last updated 03/18/2020 - About 6 years ago
Identifiers
MN License # 360
MN Medicaid 221967100
1 Some organization health care providers are made up of components that furnish different types of health care or have separate physical locations where health care is furnished. These components and physical locations are not themselves legal entities, but are part of the organization health care provider (which is a legal entity). A covered organization provider may decide that its subparts (if it has any) should have their own NPI numbers. If a subpart conducts any HIPAA standard transactions on its own (e.g., separately from its parent), it must obtain its own NPI number.

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