Provider Demographics
NPI:1457549800
Name:PRODIGY OPTICAL, INC
Entity Type:Organization
Organization Name:PRODIGY OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOJTANOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-597-5252
Mailing Address - Street 1:314 IVY AVE SE
Mailing Address - Street 2:PO BOX 680
Mailing Address - City:RICHMOND
Mailing Address - State:MN
Mailing Address - Zip Code:56368-4509
Mailing Address - Country:US
Mailing Address - Phone:320-597-5252
Mailing Address - Fax:320-597-5250
Practice Address - Street 1:314 IVY AVE SE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MN
Practice Address - Zip Code:56368-4509
Practice Address - Country:US
Practice Address - Phone:320-597-5252
Practice Address - Fax:320-597-5250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier