Healthcare Provider Details

I. General information

NPI: 1144357211
Provider Name (Legal Business Name): FORKS OPTOMETRIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 DEMERS AVE
EAST GRAND FORKS MN
56721-1835
US

IV. Provider business mailing address

421 DEMERS AVE
EAST GRAND FORKS MN
56721-1835
US

V. Phone/Fax

Practice location:
  • Phone: 218-773-3438
  • Fax: 218-773-1645
Mailing address:
  • Phone: 218-773-3438
  • Fax: 218-773-1645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateMN

VIII. Authorized Official

Name: DR. BRUCE ALLEN STORHAUG
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 218-773-2400