NORTHWEST EYE CLINIC, LLC
NPI 1164508917
Ophthalmology in Maple Grove, MN
About Northwest Eye Clinic, Llc NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
NORTHWEST EYE CLINIC, LLC (NPI 1164508917) is a healthcare organization registered as an ophthalmology in Maple Grove, Minnesota and active in the NPI registry since October 2006. The organization holds 5 active CLIA laboratory certificates and lists Kelly Pettengill, Credentialing And Data Management, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
Other Identifiers 1
Group Practice 1
Medicare Participation & PECOS CMS
Medicare enrollment, revalidation and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
Northwest Eye Clinic, Llc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Medicare Revalidation Due Date
Revalidation due by December 31, 2026
Medicare-enrolled providers and suppliers confirm their enrollment information with CMS on a set cycle, every 5 years for most and every 3 years for medical equipment suppliers. CMS sets the due date for each enrollment.
Clinicians Billing Medicare Through This Organization
22Medicare enrollment records show 22 clinicians reassign Medicare billing to Northwest Eye Clinic, LLC, which bills Medicare for the services they deliver. Of these, 3 practice at this address and 18 within 10 miles. Listed here are the 20 practicing nearest to this location.
Clinicians by Medicare Specialty 2
Nearest to this location (20)
See all 22Maple Grove, MN 55369
Maple Grove, MN 55369
Maple Grove, MN 55369
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA 5
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate of Waiver 24D2122616
Northwest Eye Clinic, LLC · Maple Grove, MNCertificate of Waiver 24D2104906
Northwest Eye Clinic, LLC · Golden Valley, MNCertificate of Waiver 24D2288569
Northwest Eye Clinic, LLC · Minnetonka, MNCertificate of Waiver 24D2122617
Northwest Eye Clinic, LLC · Wayzata, MNCertificate of Waiver 24D2122618
Northwest Eye Clinic, LLC · Saint Anthony, MNFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Northwest Eye Clinic, LLC's NPI number?
The NPI number for Northwest Eye Clinic, LLC is 1164508917. It was assigned to this organization in the NPPES registry on October 27, 2006.
Where is Northwest Eye Clinic, LLC located?
Northwest Eye Clinic, LLC is located at 12000 Elm Creek Blvd N Ste 100, Maple Grove, MN 55369. The listed phone number is (763) 416-7600.
What is Northwest Eye Clinic, LLC's specialty?
The primary specialty registered for this NPI is Ophthalmology with taxonomy code 207W00000X.
Is Northwest Eye Clinic, LLC enrolled in Medicare?
Yes. Northwest Eye Clinic, LLC is registered in the Medicare PECOS enrollment system.
When is Northwest Eye Clinic, LLC's Medicare revalidation due?
According to the CMS Revalidation Due Date List (October 2026 release), the Medicare Non-DME Part B enrollment for this organization (Minnesota, Clinic/Group Practice) is due for revalidation by December 31, 2026. Medicare providers and suppliers revalidate their enrollment every 5 years, and medical equipment suppliers every 3 years. Confirm current requirements with your Medicare Administrative Contractor.
How many clinicians bill Medicare through Northwest Eye Clinic, LLC?
According to the CMS Revalidation Reassignment List (October 2026 release), 22 clinicians in 2 Medicare specialties reassign their Medicare billing to Northwest Eye Clinic, LLC. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. The largest specialties are Ophthalmology (16) and Optometry (6). Of these, 3 practice at this address and 18 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does Northwest Eye Clinic, LLC hold CLIA laboratory certificates?
Yes. 5 active CLIA laboratory certificates are associated with this NPI under the federal Clinical Laboratory Improvement Amendments program. The certificates are listed in the CLIA Laboratory Certificates section above.
When was this NPI record last updated?
The NPPES record for Northwest Eye Clinic, LLC was last updated on March 18, 2020. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 6 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Northwest Eye Clinic, Llc · NPI 1164508917
Ophthalmology organization in Maple Grove, Minnesota. Organization record, active in the CMS NPPES registry since October 27, 2006.
## Identity
- **NPI:** 1164508917 (Entity type: Organization)
- **Enumerated:** October 27, 2006
- **Primary specialty:** Ophthalmology · taxonomy 207W00000X
- **Organization subpart:** No
- **Authorized official:** Kelly Pettengill, CREDENTIALING AND DATA MANAGEMENT
## Practice location
- **Address:** 12000 ELM CREEK BLVD N STE 100, Maple Grove, MN 55369-7074
- **Phone:** (763) 416-7600 · **Fax:** (763) 416-7634
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Medicare revalidation due:** December 31, 2026 (Non-DME Part B, Minnesota, Clinic/Group Practice) · CMS Revalidation Due Date List, October 2026 release
- **Clinicians billing through this organization:** 22 clinicians in 2 Medicare specialties reassign Medicare billing to this organization (form CMS-855R); largest: Ophthalmology (16), Optometry (6); 3 practice at this address and 18 within 10 miles; [full list](https://npiprofile.com/npi/1164508917/clinicians) · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** March 18, 2020
- **Other identifiers:** Medicaid 221967100 (MN)
- **CLIA laboratory certificates:** 5 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1164508917) · Data from the CMS NPPES public registry.