Healthcare Provider Details

I. General information

NPI: 1952383713
Provider Name (Legal Business Name): PRAIRIE VISION CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 11TH ST N SUITE A
WAHPETON ND
58075-4101
US

IV. Provider business mailing address

315 11TH ST N SUITE A
WAHPETON ND
58075-4101
US

V. Phone/Fax

Practice location:
  • Phone: 701-642-4090
  • Fax: 701-642-9424
Mailing address:
  • Phone: 701-642-4090
  • Fax: 701-642-9424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number514
License Number StateND

VIII. Authorized Official

Name: DR. WILLIAM J WELDER
Title or Position: OWNER/ OPTOMETRIST
Credential: OD
Phone: 701-642-4090