1730173238 NPI number — CAVALIER OPTOMETRY CLINIC LTD

Table of content: (NPI 1730173238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730173238 NPI number — CAVALIER OPTOMETRY CLINIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAVALIER OPTOMETRY CLINIC LTD
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:
1730173238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAVALIER
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58220-0148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-265-8315
Provider Business Mailing Address Fax Number:
701-265-8317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E 3RD AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAVALIER
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-265-8315
Provider Business Practice Location Address Fax Number:
701-265-8317
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
S
Authorized Official Middle Name:
MEREDITH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-265-8315

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  358 , 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: 0677790001 . This is a "CIGNA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 140622 . This is a "UCARE MINN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 979611041243 . This is a "PREFERRED ONE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: CLA800358 . This is a "VISION SERVICES INC" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 60162 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91398 . This is a "EYES FOR NEEDY" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 93094CA . This is a "BLUE CROSS MINNESOTA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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