Provider Demographics
NPI:1700113180
Name:PINECONE VISION THERAPY CENTER
Entity Type:Organization
Organization Name:PINECONE VISION THERAPY CENTER
Other - Org Name:PINECONE LASER CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLATRELLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-258-3915
Mailing Address - Street 1:2380 TROOP DR UNIT 201
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4637
Mailing Address - Country:US
Mailing Address - Phone:320-258-3915
Mailing Address - Fax:320-258-3917
Practice Address - Street 1:2380 TROOP DR UNIT 201
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4637
Practice Address - Country:US
Practice Address - Phone:320-258-3915
Practice Address - Fax:320-258-3917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINECONE VISION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3067152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty