Provider Demographics
NPI:1619972734
Name:20-20 OPTICAL INC
Entity type:Organization
Organization Name:20-20 OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:GAUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-998-2020
Mailing Address - Street 1:615 S MILL ST
Mailing Address - Street 2:STE 2
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2756
Mailing Address - Country:US
Mailing Address - Phone:218-998-2020
Mailing Address - Fax:218-998-2098
Practice Address - Street 1:615 S MILL ST
Practice Address - Street 2:STE 2
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2756
Practice Address - Country:US
Practice Address - Phone:218-998-2020
Practice Address - Fax:218-998-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156FX1800X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN031024003Medicaid
MN4C789TWOtherBLUE CROSS BLUE SHIELD MN
ND892886OtherND VISION SERVICES
TX21-00143Medicaid
ND55387Medicaid
AZVMN000233OtherAVESIS
1046788OtherPREFERRED ONE
MN985222100Medicaid
IN1042920001Medicare NSC