Basic Information
Provider Information | |||||||||
NPI: | 1114695731 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKY MOUNTAIN OPTICAL & CONTACT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4907 | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598064907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4065413937 | ||||||||
FaxNumber: | 4065413811 | ||||||||
Practice Location | |||||||||
Address1: | 3116 SADDLE DR STE 3 | ||||||||
Address2: |   | ||||||||
City: | HELENA | ||||||||
State: | MT | ||||||||
PostalCode: | 596018645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4064434040 | ||||||||
FaxNumber: | 4065413811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2021 | ||||||||
LastUpdateDate: | 10/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROE, CPC, CPPM, OCS | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4065413806 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.