Basic Information
| Provider Information | |||||||||
| NPI: | 1659426658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PBR OPTOMETRISTS LTD OF TRACY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 505 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561751539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076293230 | ||||||||
| FaxNumber: | 5076293230 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561751539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076293230 | ||||||||
| FaxNumber: | 5076293230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECT OWNER OF 5 PERCENT OR MORE | ||||||||
| AuthorizedOfficialTelephone: | 5076293230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 46047PB | 01 | MN | BCBS | OTHER | 112433 | 01 | MN | UCARE | OTHER | 942951013894 | 01 | MN | PREFERRED ONE | OTHER | 410011573 | 01 | RAILROAD MC | OTHER | 47621 | 01 | MN | HEALTH PARTNERS | OTHER | 697823100 | 05 | MN | MEDICAID | 5C048PB | 01 | MN | BLUE PLUS | OTHER |