1063634145 NPI number — MONTANA VALLEY EYE CLINIC, PLLC

Table of content: (NPI 1063634145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063634145 NPI number — MONTANA VALLEY EYE CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTANA VALLEY EYE CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063634145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2687 PALMER ST STE C2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59808-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-728-0044
Provider Business Mailing Address Fax Number:
406-728-0494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2687 PALMER ST STE C2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59808-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-728-0044
Provider Business Practice Location Address Fax Number:
406-728-0494
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEUMEISTER
Authorized Official First Name:
RICK
Authorized Official Middle Name:
DON
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
406-728-0044

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  6078 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000012614 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000012648 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000012920 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000109694 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002239600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-14442-7 . This is a "ST FUND" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 180034859 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 9622-0 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0550409 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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