Provider Demographics
NPI:1932305489
Name:DR PETRONACK & ASSOCIATES OPTOMETRISTS INC
Entity Type:Organization
Organization Name:DR PETRONACK & ASSOCIATES OPTOMETRISTS INC
Other - Org Name:FRIDLEY OPTICAL & EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRONACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-784-3997
Mailing Address - Street 1:7510 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2614
Mailing Address - Country:US
Mailing Address - Phone:763-784-3997
Mailing Address - Fax:763-208-7958
Practice Address - Street 1:7510 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2614
Practice Address - Country:US
Practice Address - Phone:763-784-3997
Practice Address - Fax:763-208-7958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty