Healthcare Provider Details

I. General information

NPI: 1891995460
Provider Name (Legal Business Name): WARREN EYE CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 10/31/2011
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

VIII. Authorized Official

Name: DR. STACEY JEAN BIENEK
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 218-745-5151