Provider Demographics
NPI:1679648430
Name:SWANSON EYE CLINIC, PC
Entity Type:Organization
Organization Name:SWANSON EYE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:701-265-4600
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:CAVALIER
Mailing Address - State:ND
Mailing Address - Zip Code:58220-0604
Mailing Address - Country:US
Mailing Address - Phone:701-265-4600
Mailing Address - Fax:701-265-4651
Practice Address - Street 1:105 W 2ND AVENUE N
Practice Address - Street 2:
Practice Address - City:CAVALIER
Practice Address - State:ND
Practice Address - Zip Code:58220-0604
Practice Address - Country:US
Practice Address - Phone:701-265-4600
Practice Address - Fax:701-265-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60525Medicaid
ND60622Medicaid
NDN711746Medicare ID - Type Unspecified
ND60622Medicaid
ND60525Medicaid