Provider Demographics
NPI:1710168596
Name:THE LAUREL CLINIC PLLC
Entity Type:Organization
Organization Name:THE LAUREL CLINIC PLLC
Other - Org Name:THE LAUREL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:VANNICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-628-4955
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-0445
Mailing Address - Country:US
Mailing Address - Phone:406-628-4955
Mailing Address - Fax:406-628-4362
Practice Address - Street 1:319 1ST AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-3031
Practice Address - Country:US
Practice Address - Phone:406-628-4955
Practice Address - Fax:406-628-4362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty