Organization
BIRCH LAKE VISION GROUP, LLC.
Active
Other names
Birch Lake Eye Clinic, Oak Tree Optical, Village Eye Clinic and Optica
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRIAN DWIGHT GRUDEM O.D. (CFO)
(651) 426-2747
Entity
Organization
Contact information
Practice address
4720 WHITE BEAR PKWY, WHITE BEAR LAKE, MN 55110-3336
(651) 426-2747
(651) 426-9838
Mailing address
4720 WHITE BEAR PKWY, WHITE BEAR LAKE, MN 55110-3336
(651) 426-2747
(651) 426-9838
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
LD1732000
MN
152W00000X
Optometrist
LD2695000
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22-01733
MEDICA (BIRCH LAKE)
MN
01
—
22-02690
MEDICA (BIRCH LAKE)
MN
01
—
22-02779
MEDICA (VILLAGE)
MN
01
—
22-02780
MEDICA (VILLAGE CLINIC)
MN
01
—
244ROLU
BLUE CROSS BLUE SHIELD
MN
01
—
965400656001
PREFERRED ONE
MN
01
—
965401019270
PREFERRED ONE
MN
01
—
HP27080
HEALTH PARTNERS
MN
01
—
HP29577
HEALTH PARTNERS
MN
01
—
ON456GR
BCBS
MN
01
—
P00116310
MEDICARE RAILROAD RETIREM
MN
01
—
P00124841
MEDICARE RAILROAD RETIREM
MN
Enumeration date
01/25/2007
Last updated
12/02/2009
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