Provider Demographics
NPI:1407896673
Name:LISBON VISION CENTER, P.C.
Entity Type:Organization
Organization Name:LISBON VISION CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MAIRS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-683-5815
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-0916
Mailing Address - Country:US
Mailing Address - Phone:701-683-5815
Mailing Address - Fax:701-683-9966
Practice Address - Street 1:17 11TH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-0916
Practice Address - Country:US
Practice Address - Phone:701-683-5815
Practice Address - Fax:701-683-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60633Medicaid
ND1407896673OtherWCP WORKERS COMP
ND5793850001Medicare NSC
ND60633Medicaid