Provider Demographics
NPI:1659326205
Name:FARGO VISION ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:FARGO VISION ASSOCIATES, P.C.
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOEPPE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-280-3000
Mailing Address - Street 1:3232 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-280-3000
Mailing Address - Fax:701-280-1304
Practice Address - Street 1:3232 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-280-3000
Practice Address - Fax:701-280-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
70939Medicare ID - Type Unspecified