Provider Demographics
NPI:1629076245
Name:WEIR EYE CLINIC LLC
Entity Type:Organization
Organization Name:WEIR EYE CLINIC LLC
Other - Org Name:WEIR EYE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-483-2200
Mailing Address - Street 1:849 3RD AVE W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3810
Mailing Address - Country:US
Mailing Address - Phone:701-483-2200
Mailing Address - Fax:701-483-9333
Practice Address - Street 1:849 3RD AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3810
Practice Address - Country:US
Practice Address - Phone:701-483-2200
Practice Address - Fax:701-483-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND459152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT356694OtherMT MEDICAID
NDDE6860OtherPALMETTO GBA-RR MEDICARE
ND60630Medicaid
NDN711790Medicare PIN
NDDE6860OtherPALMETTO GBA-RR MEDICARE
T66952Medicare UPIN