Provider Demographics
NPI:1437296662
Name:TERRY WALSH, PC
Entity Type:Organization
Organization Name:TERRY WALSH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-433-7290
Mailing Address - Street 1:987 14TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3311
Mailing Address - Country:US
Mailing Address - Phone:701-281-7087
Mailing Address - Fax:
Practice Address - Street 1:4831 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7206
Practice Address - Country:US
Practice Address - Phone:701-433-7290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01788002OtherBS OF ND
ND60640Medicaid
ND01788002OtherBS OF ND