Provider Demographics
NPI:1609062272
Name:MICHAEL REXINE OD PC
Entity Type:Organization
Organization Name:MICHAEL REXINE OD PC
Other - Org Name:EYES ON BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:REXINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-786-2666
Mailing Address - Street 1:32 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257-1314
Mailing Address - Country:US
Mailing Address - Phone:701-786-2666
Mailing Address - Fax:701-786-2292
Practice Address - Street 1:32 MAIN ST W
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257-1314
Practice Address - Country:US
Practice Address - Phone:701-786-2666
Practice Address - Fax:701-786-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60602Medicaid
ND60602Medicaid
NDN711316Medicare PIN