Provider Demographics
NPI:1356492946
Name:CHAMBERLAIN, NICHOLAS S (OD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WESTVIEW PARK PL
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3074
Mailing Address - Country:US
Mailing Address - Phone:406-755-5910
Mailing Address - Fax:406-756-5701
Practice Address - Street 1:580 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3074
Practice Address - Country:US
Practice Address - Phone:406-755-5910
Practice Address - Fax:406-756-5701
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTM727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0482545Medicaid
MT25084Medicare ID - Type Unspecified
MT0482545Medicaid