1770543779 NPI number — EYE CLINIC OF GREAT FALLS, P.C.

Table of content: (NPI 1770543779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770543779 NPI number — EYE CLINIC OF GREAT FALLS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CLINIC OF GREAT FALLS, 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:
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:
1770543779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT FALLS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59403-3427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-452-9507
Provider Business Mailing Address Fax Number:
406-452-2015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 2ND AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-452-9507
Provider Business Practice Location Address Fax Number:
406-452-2015
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STIBEL
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
406-452-9507

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  470 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 568 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 794 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 26540 . This is a "BC" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0480480 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25743 . This is a "BC" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0483353 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28000 . This is a "BC" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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