Provider Demographics
NPI:1235249475
Name:FAMILY VISION CLINIC LLC
Entity Type:Organization
Organization Name:FAMILY VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:HEIL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-333-8243
Mailing Address - Street 1:111 E CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0412
Mailing Address - Country:US
Mailing Address - Phone:701-222-1420
Mailing Address - Fax:701-255-2414
Practice Address - Street 1:111 E CENTURY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0412
Practice Address - Country:US
Practice Address - Phone:701-222-1420
Practice Address - Fax:701-255-2414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455794Medicaid