1558587295 NPI number — BECKER OPTOMETRY PC

Table of content: (NPI 1558587295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558587295 NPI number — BECKER OPTOMETRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BECKER OPTOMETRY PC
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:
1558587295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 34TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILWORTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56529-1801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-233-9839
Provider Business Mailing Address Fax Number:
218-233-9841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 34TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILWORTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56529-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-9839
Provider Business Practice Location Address Fax Number:
218-233-9841
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BECKER
Authorized Official First Name:
COREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-230-8890

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2951 , 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: 320M3BE . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22-02554 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: C03643 . This is a "ORGANIZATION GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 25104 . This is a "SPECTERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 091658700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 892871 . This is a "ND VISION SERVICES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00263877 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 37839 . This is a "AVESIS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 49006 . This is a "DAVIS VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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