1124153812 NPI number — PBR OPTOMETRISTS LTD OF WINDOM

Table of content: (NPI 1124153812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124153812 NPI number — PBR OPTOMETRISTS LTD OF WINDOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PBR OPTOMETRISTS LTD OF WINDOM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124153812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1006 4TH AVE
Provider Second Line Business Mailing Address:
PO BOX 160
Provider Business Mailing Address City Name:
WINDOM
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56101-1440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-831-2429
Provider Business Mailing Address Fax Number:
507-831-4243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDOM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56101-1440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-831-2429
Provider Business Practice Location Address Fax Number:
507-831-4243
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TEMME
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
507-831-2429

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2062 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 48670PB . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2200203 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 112803 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 48677PB . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 942941013468 . This is a "PREFFEREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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