Healthcare Provider Details

I. General information

NPI: 1700899143
Provider Name (Legal Business Name): MICHAEL KENNETH REXINE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 MAIN ST W
MAYVILLE ND
58257-1314
US

IV. Provider business mailing address

32 MAIN ST W
MAYVILLE ND
58257-1314
US

V. Phone/Fax

Practice location:
  • Phone: 701-786-2666
  • Fax: 701-786-2292
Mailing address:
  • Phone: 701-786-2666
  • Fax: 701-786-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number575
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: