=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922103233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY VISION CLINIC LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 1/2 7TH STREET NORTH
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-734-8137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 1/2 7TH STREET NORTH
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-734-8137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. AMY M FLECK
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 701-734-8137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 530
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------