Provider Demographics
NPI:1851445464
Name:GRANITE FALLS EYECARE INC.
Entity Type:Organization
Organization Name:GRANITE FALLS EYECARE INC.
Other - Org Name:GRANITE FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:TRUDEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-564-4997
Mailing Address - Street 1:870 PRENTICE ST
Mailing Address - Street 2:P.O. BOX 127
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241-1521
Mailing Address - Country:US
Mailing Address - Phone:320-564-4997
Mailing Address - Fax:320-564-2020
Practice Address - Street 1:870 PRENTICE ST
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56241-1521
Practice Address - Country:US
Practice Address - Phone:320-564-4997
Practice Address - Fax:320-564-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN645512300Medicaid
MN645512300Medicaid
MN5176240001Medicare NSC
MNCD1445Medicare PIN
MNC03638Medicare PIN