Healthcare Provider Details

I. General information

NPI: 1457549800
Provider Name (Legal Business Name): PRODIGY OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 IVY AVE SE
RICHMOND MN
56368-4509
US

IV. Provider business mailing address

314 IVY AVE SE PO BOX 680
RICHMOND MN
56368-4509
US

V. Phone/Fax

Practice location:
  • Phone: 320-597-5252
  • Fax: 320-597-5250
Mailing address:
  • Phone: 320-597-5252
  • Fax: 320-597-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. DIANE WOJTANOWICZ
Title or Position: OWNER
Credential:
Phone: 320-597-5252