Healthcare Provider Details

I. General information

NPI: 1659426658
Provider Name (Legal Business Name): PBR OPTOMETRISTS LTD OF TRACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 STATE STREET
TRACY MN
56175-1539
US

IV. Provider business mailing address

505 STATE STREET
TRACY MN
56175-1539
US

V. Phone/Fax

Practice location:
  • Phone: 507-629-3230
  • Fax: 507-629-3230
Mailing address:
  • Phone: 507-629-3230
  • Fax: 507-629-3230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. STEVEN J PETERSON
Title or Position: DIRECT OWNER OF 5 PERCENT OR MORE
Credential: OD
Phone: 507-629-3230