Provider Demographics
NPI:1124035191
Name:PINE RIVER EYE CENTER, INC.
Entity Type:Organization
Organization Name:PINE RIVER EYE CENTER, INC.
Other - Org Name:ASSOCIATES IN EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-587-2020
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:PINE RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56474-0457
Mailing Address - Country:US
Mailing Address - Phone:218-587-2020
Mailing Address - Fax:218-587-3229
Practice Address - Street 1:424 BARCLAY AVE.
Practice Address - Street 2:
Practice Address - City:PINE RIVER
Practice Address - State:MN
Practice Address - Zip Code:56474-0457
Practice Address - Country:US
Practice Address - Phone:218-587-2020
Practice Address - Fax:218-587-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU74864Medicare UPIN
MNT65835Medicare UPIN