| NPI | 1164508917 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLY PETTENGILL Credentialing And Data Management 763-416-7629 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207W00000X Ophthalmology (Licence: MN 360) |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2020-03-18 |