Provider Demographics
NPI:1699730036
Name:BIENEK, STACEY JEAN (OO)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:JEAN
Last Name:BIENEK
Suffix:
Gender:F
Credentials:OO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W JOHNSON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1118
Mailing Address - Country:US
Mailing Address - Phone:218-745-5151
Mailing Address - Fax:218-745-6000
Practice Address - Street 1:205 W JOHNSON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1118
Practice Address - Country:US
Practice Address - Phone:218-745-5151
Practice Address - Fax:218-745-6000
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2847152W00000X
ND609152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN779407000Medicaid
MN410002410Medicare PIN
MN779407000Medicaid