Provider Demographics
NPI:1437175882
Name:GILTHVEDT EYECARE CLINIC, INC
Entity type:Organization
Organization Name:GILTHVEDT EYECARE CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-451-3072
Mailing Address - Street 1:2560 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4305
Mailing Address - Country:US
Mailing Address - Phone:507-451-3072
Mailing Address - Fax:507-451-4291
Practice Address - Street 1:2560 HARVEST LN
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4305
Practice Address - Country:US
Practice Address - Phone:507-451-3072
Practice Address - Fax:507-451-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460867400Medicaid
MNC02665Medicare PIN
MN460867400Medicaid