1548440019 NPI number — LAGRECA EYE CLINIC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548440019 NPI number — LAGRECA EYE CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGRECA EYE CLINIC PC
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:
6
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:
1548440019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2475 VILLAGE LN
Provider Second Line Business Mailing Address:
#202
Provider Business Mailing Address City Name:
BILLINGS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59102-2497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-252-6608
Provider Business Mailing Address Fax Number:
406-252-6600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANDER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82520-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-332-5272
Provider Business Practice Location Address Fax Number:
307-332-9481
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PROCTOR
Authorized Official First Name:
LOLA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
406-294-6586

Provider Taxonomy Codes

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

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

  • Identifier: 104306400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK2875 . This is a "WY RR MCARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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