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General NPI Number Information
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NPI Number | 1790830701
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Entity Type | Organization
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Legal Business Name | PINECONE VISION CENTER, PA
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 06/28/2022
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Provider Practice Location Address
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Address Line | 2180 TROOP DR
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City | SARTELL
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State | MN
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Zip | 56377-7504
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Country | US
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Telephone | 320-258-3915
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Fax | 320-258-3917
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Provider Business Mailing Address
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Address Line | 2180 TROOP DR
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City | SARTELL
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State | MN
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Zip | 56377-4563
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Country | US
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Telephone | 320-258-3915
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Fax | 320-258-3917
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. NICHOLAS COLATRELLA
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Credential | O.D.
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Telephone | 320-258-3915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2617
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License Number State | MN
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