1073812418 NPI number — PINE RIVER EYE CENTER, INC.

Table of content: (NPI 1073812418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073812418 NPI number — PINE RIVER EYE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE RIVER EYE CENTER, 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:
6
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:
1073812418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5457 CITY HALL ST.
Provider Second Line Business Mailing Address:
PO BOX 349
Provider Business Mailing Address City Name:
NISSWA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56468-0349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-963-2020
Provider Business Mailing Address Fax Number:
218-963-9811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5457 CITY HALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NISSWA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56468-0349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-963-2020
Provider Business Practice Location Address Fax Number:
218-963-9811
Provider Enumeration Date:
03/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MARVIN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
218-587-2020

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 197023200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0579750001 . This is a "DMERC PTAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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