Healthcare Provider Details

I. General information

NPI: 1679648430
Provider Name (Legal Business Name): SWANSON EYE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 2ND AVENUE N
CAVALIER ND
58220-0604
US

IV. Provider business mailing address

PO BOX 604
CAVALIER ND
58220-0604
US

V. Phone/Fax

Practice location:
  • Phone: 701-265-4600
  • Fax: 701-265-4651
Mailing address:
  • Phone: 701-265-4600
  • Fax: 701-265-4651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number576
License Number StateND

VIII. Authorized Official

Name: DR. SOPHIA SWANSON
Title or Position: OWNER
Credential: D.O.
Phone: 701-265-4600