Provider Demographics
NPI:1093287849
Name:BONNER EYE CLINIC OPTICAL LLC
Entity Type:Organization
Organization Name:BONNER EYE CLINIC OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:JERRY
Authorized Official - Last Name:MARIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-326-3433
Mailing Address - Street 1:1542 GOLF COURSE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3537
Mailing Address - Country:US
Mailing Address - Phone:218-326-3433
Mailing Address - Fax:218-326-3435
Practice Address - Street 1:1542 GOLF COURSE RD STE 201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3537
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies