=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831156645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST EYE CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 09/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 HY 59 SE SUITE 1
-----------------------------------------------------
City | THIEF RIVER FALLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-681-3300
-----------------------------------------------------
Fax | 218-681-6733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 505 1720 HWY 59 SE SUITE 1
-----------------------------------------------------
City | THIEF RIVER FALLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-681-3300
-----------------------------------------------------
Fax | 218-681-6733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHRISTOPHER J BORGEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 218-681-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2833
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2803
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------