Provider Demographics
NPI:1629283155
Name:ADVANCED EYECARE LLC
Entity Type:Organization
Organization Name:ADVANCED EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-577-2507
Mailing Address - Street 1:4265 FALLON ST.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6756
Mailing Address - Country:US
Mailing Address - Phone:406-587-0668
Mailing Address - Fax:406-587-0396
Practice Address - Street 1:4265 FALLON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6756
Practice Address - Country:US
Practice Address - Phone:406-587-0668
Practice Address - Fax:406-587-0396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0483288Medicaid
MT000083901Medicare PIN