Organization
BLAINE EYE CLINIC OPTOMETRISTS, P.A.
Active
Organization
BLAINE EYE CLINIC OPTOMETRISTS, P.A.
Active
Other names
Blaine Eye Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
LYNN ALAN SULERUD O.D. (OWNER)
(763) 757-7000
Entity
Organization
Contact information
Practice address
12170 ABERDEEN ST NE, BLAINE, MN 55449-4716
(763) 757-7000
(763) 757-3328
Mailing address
12170 ABERDEEN ST NE, BLAINE, MN 55449-4716
(763) 757-7000
(763) 757-3328
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
MN
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
221526800
—
MN
01
—
DB3402
RAILROAD MEDICARE
MN
Enumeration date
01/19/2007
Last updated
02/15/2011
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