Provider Demographics
NPI:1538209390
Name:EYE CLINIC OF GREAT FALLS, PC
Entity type:Organization
Organization Name:EYE CLINIC OF GREAT FALLS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUMM
Authorized Official - Suffix:
Authorized Official - Credentials:OPTOMETRIST OD
Authorized Official - Phone:406-452-9507
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442
Mailing Address - Country:US
Mailing Address - Phone:406-622-5449
Mailing Address - Fax:406-622-6188
Practice Address - Street 1:1516 CHOUTEAU STREET
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442
Practice Address - Country:US
Practice Address - Phone:406-622-5449
Practice Address - Fax:406-622-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT25781OtherBLUE CROSS BLUE SHIELD
MT0483730Medicaid
U34104Medicare UPIN