Provider Demographics
NPI: | 1497116677 |
---|---|
Name: | ETERNAL VISION, P.C. |
Entity Type: | Organization |
Organization Name: | ETERNAL VISION, P.C. |
Other - Org Name: | PEARLE VISION |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | CHAD |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BEYNON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 605-520-1929 |
Mailing Address - Street 1: | 905 29TH ST SE |
Mailing Address - Street 2: | |
Mailing Address - City: | WATERTOWN |
Mailing Address - State: | SD |
Mailing Address - Zip Code: | 57201-9123 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 605-520-1929 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1612 EGLIN ST |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | RAPID CITY |
Practice Address - State: | SD |
Practice Address - Zip Code: | 57701-6110 |
Practice Address - Country: | US |
Practice Address - Phone: | 605-348-4778 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-03-15 |
Last Update Date: | 2016-03-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SD | 609 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty |