Basic Information
| Provider Information | |||||||||
| NPI: | 1467641597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL EYE SURGERY CENTER INC | ||||||||
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| OtherOrganizationName: | REGIONAL EYE ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1455 MONTREAL ST SE | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553503318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205876308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | WALLYN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9524429770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.