Provider Demographics
NPI:1538363478
Name:GRANITE CITY FAMILY EYE CARE PA
Entity type:Organization
Organization Name:GRANITE CITY FAMILY EYE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:320-251-8061
Mailing Address - Street 1:414 GREAT OAK DR
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-2504
Mailing Address - Country:US
Mailing Address - Phone:320-251-8061
Mailing Address - Fax:320-202-8031
Practice Address - Street 1:414 GREAT OAK DR
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-2504
Practice Address - Country:US
Practice Address - Phone:320-251-8061
Practice Address - Fax:320-202-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410002837Medicaid
1710903562OtherNPI
V07233OtherUPIN
V07233OtherUPIN
MNC04670OtherMEDICARE GROUP NUMBER