NPIMap

Organization Active NPI

Park Nicollet Health Care Products

  • Eyewear Supplier
  • St Louis Park, MN
National Provider Identifier
1609838614
Registry record updated Sep 24, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
PARK NICOLLET HEALTH CARE PRODUCTS
Practice address
Eye Care and Optical Store
3900 Park Nicollet Blvd Ste 120
St Louis Park, MN 55416-2503
Phone
(952) 993-3150
Fax
(952) 993-0562
NPI assigned
Apr 5, 2006
Last updated
Sep 24, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PARK NICOLLETAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 24, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kristin Denise Brey, SUPERVISOR
Title
Delegated Official
Phone
(952) 993-6832

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X NU Primary

Addresses

Primary practice location

Eye Care and Optical Store
3900 Park Nicollet Blvd Ste 120
St Louis Park, MN 55416-2503

Mailing address

PN HCP-Eye Care and Optical Store
3800 Park Nicollet Blvd # Ms 61901C
St Louis Park, MN 55416-2527
Phone (952) 993-3150

Other identifiers 1

IdentifierTypeStateIssuer
21398500MedicaidMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930016265 MN DME Supplier - Optician 2365655164 Practice locations: Saint Louis Park, MN

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Park Nicollet10 organizations share this tax ID, including this one
Part of
Park Nicollet

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144195200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1758672000000",
    "number": "1609838614",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PN HCP-EYE CARE AND OPTICAL STORE",
            "address_2": "3800 PARK NICOLLET BLVD # MS 61901C",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554162527",
            "telephone_number": "952-993-3150",
            "fax_number": "952-993-0562"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "EYE CARE AND OPTICAL STORE",
            "address_2": "3900 PARK NICOLLET BLVD STE 120",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554162503",
            "telephone_number": "952-993-3150",
            "fax_number": "952-993-0562"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PARK NICOLLET HEALTH CARE PRODUCTS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PARK NICOLLET",
        "enumeration_date": "2006-04-05",
        "last_updated": "2025-09-24",
        "certification_date": "2025-09-24",
        "status": "A",
        "authorized_official_last_name": "BREY",
        "authorized_official_first_name": "KRISTIN",
        "authorized_official_middle_name": "DENISE",
        "authorized_official_title_or_position": "DELEGATED OFFICIAL",
        "authorized_official_telephone_number": "952-993-6832",
        "authorized_official_credential": "SUPERVISOR"
    },
    "taxonomies": [
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "21398500",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in St Louis Park, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.