Healthcare Provider Details

I. General information

NPI: 1174649735
Provider Name (Legal Business Name): NODAK OPTICS DBA PEARLE VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S COLUMBIA RD
GRAND FORKS ND
58201-6076
US

IV. Provider business mailing address

2800 S COLUMBIA RD
GRAND FORKS ND
58201-6076
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-9701
  • Fax: 701-780-9084
Mailing address:
  • Phone: 701-780-9701
  • Fax: 701-780-9084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number17321100
License Number StateND

VIII. Authorized Official

Name: MR. DAVID A PEDERSON
Title or Position: OWNER
Credential:
Phone: 701-780-9701