Healthcare Provider Details

I. General information

NPI: 1972563815
Provider Name (Legal Business Name): NORTH DAKOTA EYE CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 S 42ND ST.
GRAND FORKS ND
58201-5820
US

IV. Provider business mailing address

1820 S 42ND ST.
GRAND FORKS ND
58201-4018
US

V. Phone/Fax

Practice location:
  • Phone: 17-775-3151
  • Fax: 701-775-3153
Mailing address:
  • Phone: 701-775-3151
  • Fax: 701-775-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number8411
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8411
License Number StateND

VIII. Authorized Official

Name: DR. MARK L. SCZEPANSKI
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 701-775-3151