Provider Demographics
NPI:1669565412
Name:WADENA EYE CLINIC LTD
Entity type:Organization
Organization Name:WADENA EYE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-631-2020
Mailing Address - Street 1:222 SOUTHEAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1567
Mailing Address - Country:US
Mailing Address - Phone:218-631-2020
Mailing Address - Fax:218-631-1892
Practice Address - Street 1:222 SOUTHEAST FIRST STREET
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1567
Practice Address - Country:US
Practice Address - Phone:218-631-2020
Practice Address - Fax:218-631-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-01-14
Provider Licenses
StateLicense IDTaxonomies
MN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57331OtherHEALTHPARTNERS
MN5C053WAOtherBLUE PLUS
MN2116301OtherMEDICA
MN297717600Medicaid
MN999995765OtherVSP-DR.TABBERT
MN83294MIOtherBLUE CROSS BLUE SHIELD
MN999995764OtherVSP-DR.MILLER
MN2116301OtherMEDICA
MN6158140001Medicare NSC
MN5C053WAOtherBLUE PLUS