1285635250 NPI number — THE EYE DOCTORS PC

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 1285635250 NPI number — THE EYE DOCTORS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EYE DOCTORS 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:
1285635250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5116 S WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57108-2677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-338-7104
Provider Business Mailing Address Fax Number:
605-575-3880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5116 S WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-2677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-338-7104
Provider Business Practice Location Address Fax Number:
605-575-3880
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SIETSTRA
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
605-338-7104

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  208 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CI5913 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57D33TH . This is a "BCBS OF MN" identifier . This identifiers is of the category "OTHER".




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