Healthcare Provider Details

I. General information

NPI: 1124153812
Provider Name (Legal Business Name): PBR OPTOMETRISTS LTD OF WINDOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 4TH AVE
WINDOM MN
56101-1440
US

IV. Provider business mailing address

1006 4TH AVE PO BOX 160
WINDOM MN
56101-1440
US

V. Phone/Fax

Practice location:
  • Phone: 507-831-2429
  • Fax: 507-831-4243
Mailing address:
  • Phone: 507-831-2429
  • Fax: 507-831-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2062
License Number StateMN

VIII. Authorized Official

Name: BRIAN D TEMME
Title or Position: OWNER
Credential: O.D.
Phone: 507-831-2429