Provider Demographics
NPI:1568407153
Name:OPTICAL OUTLOOK, P.C.
Entity Type:Organization
Organization Name:OPTICAL OUTLOOK, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MOEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-837-0022
Mailing Address - Street 1:1100 31ST AVE SW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-2007
Mailing Address - Country:US
Mailing Address - Phone:701-837-0022
Mailing Address - Fax:701-839-2005
Practice Address - Street 1:1100 31ST AVE SW
Practice Address - Street 2:SUITE 2
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-2007
Practice Address - Country:US
Practice Address - Phone:701-837-0022
Practice Address - Fax:701-839-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND22882OtherBCBS OF ND
ND60582Medicaid
NDN711211Medicare PIN
ND22882OtherBCBS OF ND
ND60582Medicaid