Provider Demographics
NPI:1134463565
Name:ADVANCED EYECARE
Entity Type:Organization
Organization Name:ADVANCED EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LAGODINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-757-2121
Mailing Address - Street 1:1401 28TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6731
Mailing Address - Country:US
Mailing Address - Phone:701-757-2121
Mailing Address - Fax:701-757-2120
Practice Address - Street 1:1401 28TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6731
Practice Address - Country:US
Practice Address - Phone:701-757-2121
Practice Address - Fax:701-757-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND538152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDU57795Medicare UPIN