Organization
ST CROIX VISION CENTER INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TRAVIS MATTHEW JOHNSON O.D. (PRESIDENT)
(651) 439-6400
Entity
Organization
Contact information
Practice address
13481 60TH ST N, SUITE 200, STILLWATER, MN 55082-1055
(651) 439-6400
(651) 439-6405
Mailing address
13481 60TH ST N, SUITE 200, STILLWATER, MN 55082-1055
(651) 439-6400
(651) 439-6405
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
LD2763000
MN
152WC0802X
Corneal and Contact Management Optometrist
LD2763000
MN
152WP0200X
Pediatric Optometrist
LD2763000
—
152WV0400X
Vision Therapy Optometrist
LD2763000
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
108J4JO
BLUE CROSS BLUE SHEILD GR
MN
05
—
904623200
—
MN
Enumeration date
09/28/2006
Last updated
08/16/2012
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