Provider Demographics
NPI:1497853717
Name:EYE CLINIC OF ND
Entity Type:Organization
Organization Name:EYE CLINIC OF ND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-255-4673
Mailing Address - Street 1:620 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4112
Mailing Address - Country:US
Mailing Address - Phone:701-255-4673
Mailing Address - Fax:701-255-4934
Practice Address - Street 1:620 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4112
Practice Address - Country:US
Practice Address - Phone:701-255-4673
Practice Address - Fax:701-255-4934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND202-001OtherBLUE SHIELD OF ND
ND013956Medicaid
SD7779480Medicaid
NDN6244Medicare ID - Type UnspecifiedPROVIDER NUMBER
SD7779480Medicaid
ND202-001OtherBLUE SHIELD OF ND