Provider Demographics
NPI:1699866244
Name:PROFESSIONAL EYECARE CENTERS, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL EYECARE CENTERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-252-5000
Mailing Address - Street 1:210 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-5553
Mailing Address - Country:US
Mailing Address - Phone:701-252-5000
Mailing Address - Fax:701-952-5005
Practice Address - Street 1:210 10TH ST SE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-5553
Practice Address - Country:US
Practice Address - Phone:701-252-5000
Practice Address - Fax:701-952-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60490Medicaid
NDN71152Medicare PIN
ND4562970001Medicare NSC