Provider Demographics
NPI:1053532929
Name:ADVANCED VISION CARE PA
Entity type:Organization
Organization Name:ADVANCED VISION CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST /CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:S
Authorized Official - Last Name:LUEHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-492-2350
Mailing Address - Street 1:223 1ST ST E STE 101
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1563
Mailing Address - Country:US
Mailing Address - Phone:952-492-2350
Mailing Address - Fax:952-492-6162
Practice Address - Street 1:223 1ST ST E STE 101
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1563
Practice Address - Country:US
Practice Address - Phone:952-492-2350
Practice Address - Fax:952-492-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110122OtherHEALTH PARTNERS CLINIC ID
MN340K6VAOtherBCBS OF MN CLINIC ID
MN480110500Medicaid
MN5670300001Medicare NSC
MNC04231Medicare ID - Type UnspecifiedCLINIC GROUP NUMBER