Provider Demographics
NPI:1942578562
Name:FORKS OPTOMETRIC, LTD.
Entity Type:Organization
Organization Name:FORKS OPTOMETRIC, LTD.
Other - Org Name:OPTICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STORHAUG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-281-6440
Mailing Address - Street 1:107 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1722
Mailing Address - Country:US
Mailing Address - Phone:218-281-6440
Mailing Address - Fax:218-281-5884
Practice Address - Street 1:107 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1722
Practice Address - Country:US
Practice Address - Phone:218-281-6440
Practice Address - Fax:218-281-5884
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORKS OPTOMETRIC, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2122937332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02185Medicare PIN
MN0458760003Medicare NSC