Provider Demographics
NPI:1790830701
Name:PINECONE VISION CENTER, PA
Entity Type:Organization
Organization Name:PINECONE VISION CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLATRELLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-258-3915
Mailing Address - Street 1:2180 TROOP DR
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4563
Mailing Address - Country:US
Mailing Address - Phone:320-258-3915
Mailing Address - Fax:320-258-3917
Practice Address - Street 1:2180 TROOP DR
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-7504
Practice Address - Country:US
Practice Address - Phone:320-258-3915
Practice Address - Fax:320-258-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2617152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1790830701Medicaid