Basic Information
| Provider Information | |||||||||
| NPI: | 1013152834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOTAL EYECARE P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80686 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591080686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066281767 | ||||||||
| FaxNumber: | 4066281769 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 BERNHARDT RD | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 590448702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066281767 | ||||||||
| FaxNumber: | 4066281769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2008 | ||||||||
| LastUpdateDate: | 04/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | JACQUELINE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4066281767 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0733 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0733 | 01 | MT | MONTANA LICENSE | OTHER |