Provider Demographics
NPI:1841381811
Name:NORTHERN LIGHTS OPTICAL INC
Entity Type:Organization
Organization Name:NORTHERN LIGHTS OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:JANEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-258-6776
Mailing Address - Street 1:620 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4112
Mailing Address - Country:US
Mailing Address - Phone:701-258-6776
Mailing Address - Fax:701-258-6848
Practice Address - Street 1:620 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4112
Practice Address - Country:US
Practice Address - Phone:701-258-6776
Practice Address - Fax:701-258-6848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND165753 00332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52593Medicaid
ND4239890001Medicare NSC
ND4239890001Medicare ID - Type Unspecified