Provider Demographics
NPI:1548440019
Name:LAGRECA EYE CLINIC PC
Entity type:Organization
Organization Name:LAGRECA EYE CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-294-6586
Mailing Address - Street 1:2475 VILLAGE LN
Mailing Address - Street 2:#202
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-2497
Mailing Address - Country:US
Mailing Address - Phone:406-252-6608
Mailing Address - Fax:406-252-6600
Practice Address - Street 1:1150 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2620
Practice Address - Country:US
Practice Address - Phone:307-332-5272
Practice Address - Fax:307-332-9481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104306400Medicaid
WYCK2875OtherWY RR MCARE
WYW9247Medicare PIN