1952383713 NPI number — PRAIRIE VISION CENTER PC

Table of content: (NPI 1952383713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952383713 NPI number — PRAIRIE VISION CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE VISION CENTER 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:
1952383713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 11TH ST N
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
WAHPETON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58075-4101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-642-4090
Provider Business Mailing Address Fax Number:
701-642-9424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 11TH ST N
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WAHPETON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58075-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-642-4090
Provider Business Practice Location Address Fax Number:
701-642-9424
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WELDER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/ OPTOMETRIST
Authorized Official Telephone Number:
701-642-4090

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  514 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06508001 . This is a "BCBS ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: DD0757 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 60611 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4C632WE . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 749459900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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