Provider Demographics
NPI:1730353160
Name:GARY L. RENIER, O.D. LTD
Entity type:Organization
Organization Name:GARY L. RENIER, O.D. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RENIER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-239-9711
Mailing Address - Street 1:101 10TH ST N
Mailing Address - Street 2:STE 120
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4600
Mailing Address - Country:US
Mailing Address - Phone:701-239-9771
Mailing Address - Fax:701-293-0944
Practice Address - Street 1:101 10TH ST N
Practice Address - Street 2:STE 120
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4600
Practice Address - Country:US
Practice Address - Phone:701-239-9771
Practice Address - Fax:701-293-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND339152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2C934REOtherBLUE CROSS OF MN
NDREN800339OtherND VISION
MN402225400Medicaid
ND824258102OtherTRICARE
ND2227152OtherMEDICA
ND11351OtherBLUE CROSS OF ND
ND60443Medicaid
ND60443Medicaid
ND410021854Medicare PIN
MN402225400Medicaid
MN2C934REOtherBLUE CROSS OF MN