Healthcare Provider Details

I. General information

NPI: 1811967706
Provider Name (Legal Business Name): SOPHIA NMI SWANSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SOPHIA NMI SWEDBERG O.D.

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S COLUMBIA RD J.C. PENNEY OPTICAL-COLUMBIA MALL
GRAND FORKS ND
58201-6076
US

IV. Provider business mailing address

14335 75TH ST NE
HOOPLE ND
58243-9444
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-4810
  • Fax: 701-746-9260
Mailing address:
  • Phone: 701-894-6205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: