Provider Demographics
NPI:1467836650
Name:PINECONE VISION CENTER
Entity type:Organization
Organization Name:PINECONE VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISSY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-258-3915
Mailing Address - Street 1:2180 TROOP DRIVE
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4563
Mailing Address - Country:US
Mailing Address - Phone:320-258-3915
Mailing Address - Fax:320-258-3917
Practice Address - Street 1:2180 TROOP DRIVE
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4563
Practice Address - Country:US
Practice Address - Phone:320-258-3915
Practice Address - Fax:320-258-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03484Medicare PIN