Healthcare Provider Details

I. General information

NPI: 1295468098
Provider Name (Legal Business Name): PINECONE VISION CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 07/08/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3274 NOTTINGHAM RD S
ST. CLOUD MN
56301
US

IV. Provider business mailing address

2180 TROOP DR
SARTELL MN
56377-4582
US

V. Phone/Fax

Practice location:
  • Phone: 320-258-3915
  • Fax: 320-258-3917
Mailing address:
  • Phone: 320-258-3915
  • Fax: 320-258-3917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHRISTINA HAUX
Title or Position: MANAGER
Credential:
Phone: 320-258-3915