Provider Demographics
NPI:1417090945
Name:WAHPETON FAMILY EYECARE CENTER, P.C.
Entity Type:Organization
Organization Name:WAHPETON FAMILY EYECARE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-642-9302
Mailing Address - Street 1:517 DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4414
Mailing Address - Country:US
Mailing Address - Phone:701-642-9302
Mailing Address - Fax:701-642-4321
Practice Address - Street 1:517 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4414
Practice Address - Country:US
Practice Address - Phone:701-642-9302
Practice Address - Fax:701-642-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
N711220Medicare ID - Type Unspecified