NPIMap

Organization Active NPI

Pinecone Vision Center, PA

  • Optometrist
  • Sartell, MN
National Provider Identifier
1790830701
Registry record updated Jun 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
2617 Issued in MN
Legal business name
PINECONE VISION CENTER, PA
Practice address
2180 Troop Dr
Sartell, MN 56377-7504
Phone
(320) 258-3915
Fax
(320) 258-3917
NPI assigned
Jan 23, 2007
Last updated
Jun 28, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 28, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Nicholas Colatrella, O.D.NPI 1467507475
Title
Medical Director
Phone
(320) 258-3915

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X 2617 MN Primary

Addresses

Primary practice location

2180 Troop Dr
Sartell, MN 56377-7504

Mailing address

2180 Troop Dr
Sartell, MN 56377-4563
Phone (320) 258-3915

Other identifiers 1

IdentifierTypeStateIssuer
1790830701MedicaidMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040319000822 MN Part B Supplier - Clinic/Group Practice 6800786906 Receives reassigned benefits from 9 practitioners
1 other NPI on this enrollment
Practice locations: Saint Cloud, MN; Sartell, MN

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Pinecone Vision Center PLLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1656374400000",
    "number": "1790830701",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2180 TROOP DR",
            "city": "SARTELL",
            "state": "MN",
            "postal_code": "563774563",
            "telephone_number": "320-258-3915",
            "fax_number": "320-258-3917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2180 TROOP DR",
            "city": "SARTELL",
            "state": "MN",
            "postal_code": "563777504",
            "telephone_number": "320-258-3915",
            "fax_number": "320-258-3917"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINECONE VISION CENTER, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-23",
        "last_updated": "2022-06-28",
        "certification_date": "2022-06-28",
        "status": "A",
        "authorized_official_last_name": "COLATRELLA",
        "authorized_official_first_name": "NICHOLAS",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "320-258-3915",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "MN",
            "license": "2617",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1790830701",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Sartell, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.