Provider Demographics
NPI:1508165572
Name:PINE RIVER EYE CENTER, INC.
Entity Type:Organization
Organization Name:PINE RIVER EYE CENTER, INC.
Other - Org Name:ASSOCIATES IN EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-587-2020
Mailing Address - Street 1:14453 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8459
Mailing Address - Country:US
Mailing Address - Phone:218-829-1789
Mailing Address - Fax:218-829-1780
Practice Address - Street 1:14453 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8459
Practice Address - Country:US
Practice Address - Phone:218-829-1789
Practice Address - Fax:218-829-1780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE RIVER EYE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN197023200Medicaid
MN0579750001OtherDMERC PTAN