Healthcare Provider Details

I. General information

NPI: 1699730036
Provider Name (Legal Business Name): STACEY JEAN BIENEK OO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W JOHNSON AVE SUITE 1
WARREN MN
56762-1118
US

IV. Provider business mailing address

205 W JOHNSON AVE SUITE 1
WARREN MN
56762-1118
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-5151
  • Fax: 218-745-6000
Mailing address:
  • Phone: 218-745-5151
  • Fax: 218-745-6000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2847
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number609
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: