Provider Demographics
NPI:1851324313
Name:PINE EYE ASSOCIATES, PA
Entity Type:Organization
Organization Name:PINE EYE ASSOCIATES, PA
Other - Org Name:PINE EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:A
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-629-7262
Mailing Address - Street 1:110 EVERGREEN SQUARE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063
Mailing Address - Country:US
Mailing Address - Phone:320-629-7262
Mailing Address - Fax:320-629-7789
Practice Address - Street 1:110 EVERGREEN SQUARE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063
Practice Address - Country:US
Practice Address - Phone:320-629-7262
Practice Address - Fax:320-629-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN644731700Medicaid
MN644731700Medicaid