Provider Demographics
NPI:1871576306
Name:SOUTHDALE OPTICAL CO
Entity type:Organization
Organization Name:SOUTHDALE OPTICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JON
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-925-9550
Mailing Address - Street 1:6533 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2103
Mailing Address - Country:US
Mailing Address - Phone:952-925-9550
Mailing Address - Fax:952-925-9748
Practice Address - Street 1:6533 DREW AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2103
Practice Address - Country:US
Practice Address - Phone:952-925-9550
Practice Address - Fax:952-925-9748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0283180001Medicare NSC