Provider Demographics
NPI:1174649735
Name:NODAK OPTICS DBA PEARLE VISION
Entity Type:Organization
Organization Name:NODAK OPTICS DBA PEARLE VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-780-9701
Mailing Address - Street 1:2800 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6076
Mailing Address - Country:US
Mailing Address - Phone:701-780-9701
Mailing Address - Fax:701-780-9084
Practice Address - Street 1:2800 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6076
Practice Address - Country:US
Practice Address - Phone:701-780-9701
Practice Address - Fax:701-780-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17321100332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18524OtherDAVIS VISION
ND102553OtherEYEMED
ND801774OtherNDVSI