Healthcare Provider Details

I. General information

NPI: 1831156645
Provider Name (Legal Business Name): NORTHWEST EYE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 HY 59 SE SUITE 1
THIEF RIVER FALLS MN
56701
US

IV. Provider business mailing address

PO BOX 505 1720 HWY 59 SE SUITE 1
THIEF RIVER FALLS MN
56701
US

V. Phone/Fax

Practice location:
  • Phone: 218-681-3300
  • Fax: 218-681-6733
Mailing address:
  • Phone: 218-681-3300
  • Fax: 218-681-6733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2833
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2803
License Number StateMN

VIII. Authorized Official

Name: CHRISTOPHER J BORGEN
Title or Position: CEO
Credential: OD
Phone: 218-681-3300