Provider Demographics
NPI:1831156645
Name:NORTHWEST EYE CENTER PA
Entity type:Organization
Organization Name:NORTHWEST EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BORGEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-681-3300
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:1720 HWY 59 SE SUITE 1
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701
Mailing Address - Country:US
Mailing Address - Phone:218-681-3300
Mailing Address - Fax:218-681-6733
Practice Address - Street 1:1720 HY 59 SE
Practice Address - Street 2:SUITE 1
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:218-681-3300
Practice Address - Fax:218-681-6733
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST EYE CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-26
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2833152W00000X
MN2803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN644201041982OtherPREF
MN928102900Medicaid
MN644201030SS1OtherPREFERRED
MN46G79B0OtherBCBS
MN736145900Medicaid
MN289M4TJOtherBCBS
U86433Medicare UPIN
MN644201030SS1OtherPREFERRED
MN410002041Medicare ID - Type Unspecified
MN410001670Medicare ID - Type Unspecified
IN4207870001Medicare NSC
GACH3627Medicare PIN