Provider Demographics
NPI:1629248448
Name:MAVES EYEWEAR, LLC
Entity Type:Organization
Organization Name:MAVES EYEWEAR, LLC
Other - Org Name:MAVES OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GANDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-773-3438
Mailing Address - Street 1:1101 S COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4055
Mailing Address - Country:US
Mailing Address - Phone:701-775-4114
Mailing Address - Fax:
Practice Address - Street 1:1101 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4055
Practice Address - Country:US
Practice Address - Phone:701-775-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND458332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
6159890001Medicare NSC