Provider Demographics
NPI:1356563803
Name:FALLS OPTICAL, INC.
Entity type:Organization
Organization Name:FALLS OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-224-5936
Mailing Address - Street 1:1850 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3381
Mailing Address - Country:US
Mailing Address - Phone:320-632-3291
Mailing Address - Fax:320-632-2392
Practice Address - Street 1:1850 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3381
Practice Address - Country:US
Practice Address - Phone:320-632-2391
Practice Address - Fax:320-632-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN173486OtherUNICARE
MN41-0049674OtherRAILROAD MEDICARE
MN257J6CLOtherBCBS
MN2203387OtherMEDICA
MN520042300Medicaid
MN41-0049674OtherRAILROAD MEDICARE