Healthcare Provider Details

I. General information

NPI: 1073812418
Provider Name (Legal Business Name): PINE RIVER EYE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 CITY HALL ST
NISSWA MN
56468-0349
US

IV. Provider business mailing address

5457 CITY HALL ST. PO BOX 349
NISSWA MN
56468-0349
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-2020
  • Fax: 218-963-9811
Mailing address:
  • Phone: 218-963-2020
  • Fax: 218-963-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL S. MARVIN
Title or Position: CEO
Credential: O.D.
Phone: 218-587-2020