Provider Demographics
NPI:1730173238
Name:CAVALIER OPTOMETRY CLINIC LTD
Entity type:Organization
Organization Name:CAVALIER OPTOMETRY CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:S
Authorized Official - Middle Name:MEREDITH
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-265-8315
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:CAVALIER
Mailing Address - State:ND
Mailing Address - Zip Code:58220-0148
Mailing Address - Country:US
Mailing Address - Phone:701-265-8315
Mailing Address - Fax:701-265-8317
Practice Address - Street 1:201 E 3RD AVE S
Practice Address - Street 2:
Practice Address - City:CAVALIER
Practice Address - State:ND
Practice Address - Zip Code:58220
Practice Address - Country:US
Practice Address - Phone:701-265-8315
Practice Address - Fax:701-265-8317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND358152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0677790001OtherCIGNA
ND140622OtherUCARE MINN
ND979611041243OtherPREFERRED ONE
NDCLA800358OtherVISION SERVICES INC
ND60162Medicaid
ND91398OtherEYES FOR NEEDY
ND93094CAOtherBLUE CROSS MINNESOTA
ND93094CAOtherBLUE CROSS MINNESOTA
NDCLA800358OtherVISION SERVICES INC