Provider Demographics
NPI:1215006416
Name:MILES CITY VISION CLINIC P C
Entity Type:Organization
Organization Name:MILES CITY VISION CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:LUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:406-234-7426
Mailing Address - Street 1:1909 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-3724
Mailing Address - Country:US
Mailing Address - Phone:406-234-7426
Mailing Address - Fax:406-234-7005
Practice Address - Street 1:1909 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-3724
Practice Address - Country:US
Practice Address - Phone:406-234-7426
Practice Address - Fax:406-234-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0482807Medicaid
MT0481039Medicaid
MT0481546Medicaid
MT0482807Medicaid
MTU21445Medicare UPIN
MT0481546Medicaid
MTT89275Medicare UPIN
MT0481039Medicaid
MTC01371Medicare ID - Type UnspecifiedRAILROAD PROVIDER NUMBER