Provider Demographics
NPI:1225686827
Name:OPTOMETRY CLINIC, PC
Entity Type:Organization
Organization Name:OPTOMETRY CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-629-0208
Mailing Address - Street 1:PO BOX 1597
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58784-1551
Mailing Address - Country:US
Mailing Address - Phone:701-629-0208
Mailing Address - Fax:
Practice Address - Street 1:28 2ND ST NW
Practice Address - Street 2:
Practice Address - City:KENMARE
Practice Address - State:ND
Practice Address - Zip Code:58746-7114
Practice Address - Country:US
Practice Address - Phone:701-385-4004
Practice Address - Fax:701-385-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty