Provider Demographics
NPI:1992806814
Name:ELY VISION - OPTOMETRY CENTER P.C.
Entity type:Organization
Organization Name:ELY VISION - OPTOMETRY CENTER P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:BREMNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-365-4919
Mailing Address - Street 1:38 E HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1240
Mailing Address - Country:US
Mailing Address - Phone:218-365-4919
Mailing Address - Fax:218-365-7770
Practice Address - Street 1:38 E HARVEY ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1240
Practice Address - Country:US
Practice Address - Phone:218-365-4919
Practice Address - Fax:218-365-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2959152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNV00152Medicare UPIN
MNC03612Medicare PIN
MN5207080001Medicare NSC