Basic Information
Provider Information | |||||||||
NPI: | 1205090321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICE | ||||||||
FirstName: | JEANNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 927 TRETTEL LANE | ||||||||
Address2: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 55720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791227 | ||||||||
FaxNumber: | 2188783755 | ||||||||
Practice Location | |||||||||
Address1: | 927 TRETTEL LANE | ||||||||
Address2: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 55720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791227 | ||||||||
FaxNumber: | 2188783755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2008 | ||||||||
LastUpdateDate: | 12/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2829 | MN | Y |   | Eye and Vision Services Providers | Optometrist |   | 152WC0802X | 2829 | MN | N |   | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
ID | Type | State | Issuer | Description | 2819571-00 | 05 | MN |   | MEDICAID |