Provider Demographics
NPI:1326025602
Name:EYEWEAR CONCEPTS INC
Entity type:Organization
Organization Name:EYEWEAR CONCEPTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OF CORPORTATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDRUS
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:701-264-1177
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58602-0149
Mailing Address - Country:US
Mailing Address - Phone:701-264-1177
Mailing Address - Fax:701-225-8148
Practice Address - Street 1:448 21ST ST W STE D1
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58602-0149
Practice Address - Country:US
Practice Address - Phone:701-264-1177
Practice Address - Fax:701-225-8148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND56209Medicaid
0288820001Medicare ID - Type Unspecified