1619972734 NPI number — 20-20 OPTICAL INC

Table of content: (NPI 1619972734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619972734 NPI number — 20-20 OPTICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
20-20 OPTICAL INC
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:
1619972734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 S MILL ST
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
FERGUS FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56537-2756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-998-2020
Provider Business Mailing Address Fax Number:
218-998-2098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 S MILL ST
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
FERGUS FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56537-2756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-998-2020
Provider Business Practice Location Address Fax Number:
218-998-2098
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GAUSTAD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
218-998-2020

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 031024003 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4C789TW . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 892886 . This is a "ND VISION SERVICES" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 21-00143 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55387 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: VMN000233 . This is a "AVESIS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1046788 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 985222100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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