MEDICARE: LEIDENIX PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	552	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669401527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEIDENIX PC

Provider Business Mailing Address
First Line	:	1000 OLD RED TRAIL NW
Second Line	:
City	:	MANDAN
State	:	ND
Zip	:	58554-3052
Country	:	US
Telephone Number	:	701-663-0012
Fax Number	:	701-663-0522

Provider Business Practice Location Address
First Line	:	2717 ROCK ISLAND PLACE
Second Line	:	SUITE 2
City	:	BISMARCK
State	:	ND
Zip	:	58504-7724
Country	:	US
Telephone Number	:	701-258-3402
Fax Number	:	701-258-7897

Authorized Official
Title or Position	:	MANAGER
Name	:	MELISSA MATTSON
Credential	:
Telephone Number	:	701-663-0012

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	10/03/2018

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Directions to “LEIDENIX PC ” Practice Location

Language	Start Address	Practice Location

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