Provider Demographics
NPI:1245829357
Name:PREMIER OPTICAL, LLC
Entity type:Organization
Organization Name:PREMIER OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:THOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-235-0561
Mailing Address - Street 1:3171 44TH ST S, STE 101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8521
Mailing Address - Country:US
Mailing Address - Phone:701-235-0561
Mailing Address - Fax:701-235-0330
Practice Address - Street 1:3171 44TH ST S, STE 101
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8521
Practice Address - Country:US
Practice Address - Phone:701-235-0561
Practice Address - Fax:701-235-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty