Provider Demographics
NPI:1568525491
Name:GLACIER OPTICIANS INC
Entity Type:Organization
Organization Name:GLACIER OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-5027
Mailing Address - Street 1:175 TIMBERWOLF PKWY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1218
Mailing Address - Country:US
Mailing Address - Phone:406-752-5027
Mailing Address - Fax:
Practice Address - Street 1:175 TIMBERWOLF PKWY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1218
Practice Address - Country:US
Practice Address - Phone:406-752-5027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0165010002Medicare NSC