Healthcare Provider Details

I. General information

NPI: 1780742270
Provider Name (Legal Business Name): BENJAMIN D STONE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 3RD ST
INTERNATIONAL FALLS MN
56649
US

IV. Provider business mailing address

340 3RD ST
INTERNATIONAL FALLS MN
56649
US

V. Phone/Fax

Practice location:
  • Phone: 218-283-4788
  • Fax:
Mailing address:
  • Phone: 218-283-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1583
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1583
License Number StateMN

VIII. Authorized Official

Name: VICKI LYNN STONE
Title or Position: BOOKKEEPER OWNER
Credential:
Phone: 218-283-4788