1932305489 NPI number — DR PETRONACK & ASSOCIATES OPTOMETRISTS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932305489 NPI number — DR PETRONACK & ASSOCIATES OPTOMETRISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR PETRONACK & ASSOCIATES OPTOMETRISTS 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:
FRIDLEY OPTICAL & EYECARE
Provider Other Organization Name Type Code:
3
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:
1932305489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7510 UNIVERSITY AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55432-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-784-3997
Provider Business Mailing Address Fax Number:
763-208-7958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7510 UNIVERSITY AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55432-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-784-3997
Provider Business Practice Location Address Fax Number:
763-208-7958
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETRONACK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-784-3997

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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