Provider Demographics
NPI:1235326398
Name:DR. L.R. MASCIARELLI & ASSOCIATES OPTOMETRY
Entity Type:Organization
Organization Name:DR. L.R. MASCIARELLI & ASSOCIATES OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MASCIARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-281-9393
Mailing Address - Street 1:4302 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3395
Mailing Address - Country:US
Mailing Address - Phone:701-281-9393
Mailing Address - Fax:
Practice Address - Street 1:4302 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3395
Practice Address - Country:US
Practice Address - Phone:701-281-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U05515Medicare UPIN
410001976Medicare PIN