Organization
MINNESOTA EYE CONSULTANTS, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRENT L WILDE (PRESIDENT)
(952) 567-6143
Entity
Organization
Contact information
Practice address
11091 ULYSSES ST NE, SUITE 300, BLAINE, MN 55434-4237
(952) 888-5800
(763) 421-8297
Mailing address
9801 DUPONT AVE S, SUITE 425, BLOOMINGTON, MN 55431-3100
(952) 888-5800
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
31920
MN
291U00000X
Clinical Medical Laboratory
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
24D2023184
CLIA
MN
Enumeration date
06/10/2010
Last updated
02/22/2017
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