Provider Demographics
NPI:1124153812
Name:PBR OPTOMETRISTS LTD OF WINDOM
Entity type:Organization
Organization Name:PBR OPTOMETRISTS LTD OF WINDOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TEMME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-831-2429
Mailing Address - Street 1:1006 4TH AVE
Mailing Address - Street 2:PO BOX 160
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1440
Mailing Address - Country:US
Mailing Address - Phone:507-831-2429
Mailing Address - Fax:507-831-4243
Practice Address - Street 1:1006 4TH AVE
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1440
Practice Address - Country:US
Practice Address - Phone:507-831-2429
Practice Address - Fax:507-831-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN48670PBOtherBLUECROSS BLUESHIELD
MN2200203OtherMEDICA
MN112803OtherUCARE MINNESOTA
MN48677PBOtherBLUE PLUS
MN942941013468OtherPREFFEREDONE
MN0261970002Medicare NSC
MNC03104Medicare PIN
MN2200203OtherMEDICA