Provider Demographics
NPI:1508354911
Name:VISION SOURCE MINOT, PLLC
Entity Type:Organization
Organization Name:VISION SOURCE MINOT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:MESKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-852-2020
Mailing Address - Street 1:1100 N BROADWAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1349
Mailing Address - Country:US
Mailing Address - Phone:701-214-2248
Mailing Address - Fax:701-852-7853
Practice Address - Street 1:1100 N BROADWAY STE 110
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-1349
Practice Address - Country:US
Practice Address - Phone:701-214-2248
Practice Address - Fax:701-852-7853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1472949Medicaid