Provider Demographics
NPI:1942351002
Name:BRAINERD EYECARE CENTER, PA
Entity Type:Organization
Organization Name:BRAINERD EYECARE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHIBALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-839-4729
Mailing Address - Street 1:506 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3526
Mailing Address - Country:US
Mailing Address - Phone:218-829-0946
Mailing Address - Fax:218-829-1279
Practice Address - Street 1:506 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3526
Practice Address - Country:US
Practice Address - Phone:218-829-0946
Practice Address - Fax:218-829-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN175471800Medicaid
MN81138SUOtherBLUE CROSS
MNCS0782Medicare PIN
MNC08278Medicare PIN
MN175471800Medicaid