Healthcare Provider Details

I. General information

NPI: 1306266291
Provider Name (Legal Business Name): HAZEN FAMILY EYECARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 12TH AVE NW SUITE #1
HAZEN ND
58545-4100
US

IV. Provider business mailing address

104 12TH AVE NW SUITE #1
HAZEN ND
58545-4100
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-5220
  • Fax: 701-748-5221
Mailing address:
  • Phone: 701-748-5220
  • Fax: 701-748-5221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number681
License Number StateND

VIII. Authorized Official

Name: DR. DEREK DAVID CZYWCZYNSKI
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 701-516-2115