Provider Demographics
NPI:1164794780
Name:STANTON L ANDRIST & CASEY C BARTZ
Entity Type:Organization
Organization Name:STANTON L ANDRIST & CASEY C BARTZ
Other - Org Name:MOORHEAD VISION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNTER/OD
Authorized Official - Prefix:
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDRIST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-233-1624
Mailing Address - Street 1:420 CENTER AVE
Mailing Address - Street 2:SUITE 41
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1957
Mailing Address - Country:US
Mailing Address - Phone:218-233-1624
Mailing Address - Fax:218-233-2058
Practice Address - Street 1:420 CENTER AVE
Practice Address - Street 2:SUITE 41
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1957
Practice Address - Country:US
Practice Address - Phone:218-233-1624
Practice Address - Fax:218-233-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2021152W00000X
MN1532152W00000X
MN3196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6682310001OtherDMERC SUPPLIER NUMBER
MNC09061Medicare PIN