Basic Information
| Provider Information | |||||||||
| NPI: | 1780047399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PLOYHAR | ||||||||
| FirstName: | CONNIE | ||||||||
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| Credential: | OPTICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4907 | ||||||||
| Address2: | 700 WEST KENT | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598016719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413937 | ||||||||
| FaxNumber: | 4065413811 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 WEST KENT | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598016719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413937 | ||||||||
| FaxNumber: | 4065413811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.