Provider Demographics
NPI:1659426658
Name:PBR OPTOMETRISTS LTD OF TRACY
Entity Type:Organization
Organization Name:PBR OPTOMETRISTS LTD OF TRACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER OF 5 PERCENT OR MORE
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:507-629-3230
Mailing Address - Street 1:505 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:MN
Mailing Address - Zip Code:56175-1539
Mailing Address - Country:US
Mailing Address - Phone:507-629-3230
Mailing Address - Fax:507-629-3230
Practice Address - Street 1:505 STATE STREET
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:MN
Practice Address - Zip Code:56175-1539
Practice Address - Country:US
Practice Address - Phone:507-629-3230
Practice Address - Fax:507-629-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN46047PBOtherBCBS
MN112433OtherUCARE
MN942951013894OtherPREFERRED ONE
410011573OtherRAILROAD MC
MN47621OtherHEALTH PARTNERS
MN697823100Medicaid
MN5C048PBOtherBLUE PLUS
410011573OtherRAILROAD MC
MN419000393Medicare PIN