Healthcare Provider Details

I. General information

NPI: 1881725737
Provider Name (Legal Business Name): CENTURY EYEWEAR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 MAIN ST S
MINOT ND
58701-3915
US

IV. Provider business mailing address

207 MAIN ST S
MINOT ND
58701-3915
US

V. Phone/Fax

Practice location:
  • Phone: 701-852-5626
  • Fax: 701-838-6723
Mailing address:
  • Phone: 701-852-5626
  • Fax: 701-838-6723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number544
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON L. BRADLEY
Title or Position: PRESIDENT/CEO
Credential: O.D.
Phone: 701-852-5626