Provider Demographics
NPI:1336235449
Name:THOMAS N LORENTZSEN & STANTON L ANDRIST PTR
Entity Type:Organization
Organization Name:THOMAS N LORENTZSEN & STANTON L ANDRIST PTR
Other - Org Name:MOORHEAD VISION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLAIMS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-233-1624
Mailing Address - Street 1:420 CENTER AVE
Mailing Address - Street 2:SUITE 41
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 CENTER AVE
Practice Address - Street 2:SUITE 41
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:218-233-1624
Practice Address - Fax:218-233-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNDG1558OtherRR MEDICARE PIN
MN281311400Medicaid
MN61093OtherBCBS PIN
NDDB3751OtherRR MEDICARE PIN
MN61093OtherBCBS PIN
NDDB3751OtherRR MEDICARE PIN
MN281311400Medicaid