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
10709 WAYZATA BLVD, SUITE 200, MINNETONKA, MN 55305-5509
(952) 888-5800
(763) 553-1137
Mailing address
9801 DUPONT AVE S, SUITE 425, BLOOMINGTON, MN 55431-3100
(952) 888-5800
(952) 567-6156
Taxonomy
Speciality
Code
Description
License number
State
152WC0802X
Corneal and Contact Management Optometrist
—
—
207W00000X
Ophthalmology Physician
Primary
—
—
291U00000X
Clinical Medical Laboratory
—
MN
332H00000X
Eyewear Supplier
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
24D2023185
CLIA
MN
05
—
680090400
—
MN
01
—
CG8516
RR MEDICARE GROUP NUMBER
MN
Enumeration date
02/14/2006
Last updated
02/22/2017
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