Provider Demographics
NPI:1710966049
Name:ADVANCED VISION CENTERS PC
Entity Type:Organization
Organization Name:ADVANCED VISION CENTERS PC
Other - Org Name:ADVANCED VISION CENTERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPTOMETRIST/CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-225-2020
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58602-0967
Mailing Address - Country:US
Mailing Address - Phone:701-225-2020
Mailing Address - Fax:701-483-5879
Practice Address - Street 1:446 3RD AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601
Practice Address - Country:US
Practice Address - Phone:701-225-2020
Practice Address - Fax:701-483-5879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND00866001OtherBLUE CROSS VISION
ND60578Medicaid
CN8225OtherRAILROAD MEDICARE
OH00729001OtherBLUE CROSS
ND00866001OtherBLUE CROSS VISION
CN8225Medicare ID - Type UnspecifiedRAILROAD
70782Medicare ID - Type Unspecified