Provider Demographics
NPI:1083769095
Name:PBR OPTOMETRISTS LTD OF SPRINGFIELD
Entity Type:Organization
Organization Name:PBR OPTOMETRISTS LTD OF SPRINGFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-629-3230
Mailing Address - Street 1:602 NORTH JACKSON AVE
Mailing Address - Street 2:PO BOX 186
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56087-0186
Mailing Address - Country:US
Mailing Address - Phone:507-723-5115
Mailing Address - Fax:507-723-6480
Practice Address - Street 1:602 NORTH JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MN
Practice Address - Zip Code:56087-0186
Practice Address - Country:US
Practice Address - Phone:507-723-5115
Practice Address - Fax:507-723-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN112984OtherUCARE
MN3C276PBOtherBLUE PLUS
3C276PBOtherBLUECROSS BLUESHIELD
MN43233PBOtherBCBS
MN898861020124OtherPREFERRED ONE
MNC07098Medicare PIN
MN3C276PBOtherBLUE PLUS