Provider Demographics
NPI:1578778296
Name:DR. PETRONACK & ASSOCIATES, OPTOMETRISTS, INC.
Entity Type:Organization
Organization Name:DR. PETRONACK & ASSOCIATES, OPTOMETRISTS, INC.
Other - Org Name:HUGO OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:PETRONACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-762-9545
Mailing Address - Street 1:5679 147TH ST N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-9302
Mailing Address - Country:US
Mailing Address - Phone:651-762-9545
Mailing Address - Fax:651-762-9542
Practice Address - Street 1:5679 147TH ST N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-9302
Practice Address - Country:US
Practice Address - Phone:651-762-9545
Practice Address - Fax:651-762-9542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003879Medicare PIN
MNC09368Medicare PIN