Provider Demographics
NPI:1932479474
Name:MOUNTAIN VALLEY VISION CENTER
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CZERNY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-390-7624
Mailing Address - Street 1:1236 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1533
Mailing Address - Country:US
Mailing Address - Phone:605-642-2645
Mailing Address - Fax:
Practice Address - Street 1:1236 NORTH AVE
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1533
Practice Address - Country:US
Practice Address - Phone:605-642-2645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9204090Medicaid
SDS105191Medicare PIN
SDS105815Medicare PIN
SD9204090Medicaid
SD6684060001Medicare NSC