Provider Demographics
NPI:1184606949
Name:RUNESTONE EYE CARE, INC.
Entity type:Organization
Organization Name:RUNESTONE EYE CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WYSOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-759-1130
Mailing Address - Street 1:3015 HIGHWAY 29 S
Mailing Address - Street 2:SUITE 4155
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3486
Mailing Address - Country:US
Mailing Address - Phone:320-759-1130
Mailing Address - Fax:
Practice Address - Street 1:3015 HIGHWAY 29 S
Practice Address - Street 2:SUITE 4155
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3486
Practice Address - Country:US
Practice Address - Phone:320-759-1130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1024868OtherPREFERRED ONE
MN971325500Medicaid
MN2200241OtherMEDICA
MN30701135OtherPRIMEWEST
MN66Q23RUOtherBCBS
MN66Q26RUOtherBCBS
MN971325500Medicaid
1296170001Medicare NSC
MN66Q23RUOtherBCBS