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General NPI Number Information
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NPI Number | 1942578562
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Entity Type | Organization
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Legal Business Name | FORKS OPTOMETRIC, LTD.
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Dates
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Enumeration Date | 12/09/2011
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 107 E 2ND ST
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City | CROOKSTON
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State | MN
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Zip | 56716-1722
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Country | US
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Telephone | 218-281-6440
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Fax | 218-281-5884
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Provider Business Mailing Address
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Address Line | 107 E 2ND ST
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City | CROOKSTON
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State | MN
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Zip | 56716-1722
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Country | US
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Telephone | 218-281-6440
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Fax | 218-281-5884
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. BRUCE A STORHAUG
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Credential | O.D.
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Telephone | 218-281-6440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 2122937
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License Number State | MN
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