Provider Demographics
NPI:1700064599
Name:ROLLA EYE CLINIC
Entity Type:Organization
Organization Name:ROLLA EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:THORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-477-5656
Mailing Address - Street 1:PO BOX 1170
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:ND
Mailing Address - Zip Code:58367-1170
Mailing Address - Country:US
Mailing Address - Phone:701-477-5656
Mailing Address - Fax:701-477-5675
Practice Address - Street 1:118 3RD ST. NE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:ND
Practice Address - Zip Code:58367-1170
Practice Address - Country:US
Practice Address - Phone:701-477-5656
Practice Address - Fax:701-477-5675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND540261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDB48107221235OtherPREFERRED
NDTHO13533OtherBCBS
ND410048131OtherMEDICARE RAIL ROAD
ND60650Medicaid
NDB48107221235OtherPREFERRED
ND=========OtherMUTUAL OF OMAHA
ND0780610001Medicare NSC