Provider Demographics
NPI:1073698601
Name:FERGUS FALLS OPTOMETRIC CENTER, LTD
Entity Type:Organization
Organization Name:FERGUS FALLS OPTOMETRIC CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:OLMSTED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-736-7555
Mailing Address - Street 1:117 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2216
Mailing Address - Country:US
Mailing Address - Phone:218-736-7555
Mailing Address - Fax:218-739-6586
Practice Address - Street 1:117 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2216
Practice Address - Country:US
Practice Address - Phone:218-736-7555
Practice Address - Fax:218-739-6586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN185787800Medicaid
MN47844FEOtherBCBS
MN185787800Medicaid
MNC02306Medicare ID - Type Unspecified