1427183664 NPI number — LAGRECA EYE CLINIC, P.C.

Table of content: (NPI 1427183664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427183664 NPI number — LAGRECA EYE CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGRECA EYE CLINIC, P.C.
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:
1427183664
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:
1150 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANDER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82520-2620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-338-5272
Provider Business Mailing Address Fax Number:
307-338-5272

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:
307-332-5272
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAGRECA
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MD PRESIDENT
Authorized Official Telephone Number:
406-252-6608

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  10106 , 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: 7090 . This is a "MT MEDICAL LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 117775303 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5205A . This is a "WYOMING MEDICAL LICENCE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 311774 . This is a "WY BCBS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 490005573 . This is a "WY RR MEDICARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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