Provider Demographics
NPI:1598944373
Name:DRS MOEN ENDERLE AND KREIN PC
Entity Type:Organization
Organization Name:DRS MOEN ENDERLE AND KREIN PC
Other - Org Name:20/20 EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-662-2040
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-0888
Mailing Address - Country:US
Mailing Address - Phone:701-662-2040
Mailing Address - Fax:701-662-2040
Practice Address - Street 1:211 4TH ST NE STE 1
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2479
Practice Address - Country:US
Practice Address - Phone:701-662-2040
Practice Address - Fax:701-662-2040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DRS MOEN ENDERLE AND KREIN PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-30
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND893212OtherVSI
NDN70449OtherMEDICARE ID GROUP
ND60570Medicaid
ND60678Medicaid
ND60570Medicaid
NDN714841Medicare PIN
ND893212OtherVSI