Provider Demographics
NPI:1972836898
Name:LAROCQUE, MISTY LYNN
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:LAROCQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4907
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-4907
Mailing Address - Country:US
Mailing Address - Phone:406-541-3918
Mailing Address - Fax:406-541-3813
Practice Address - Street 1:700 WEST KENT
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-541-3918
Practice Address - Fax:406-541-3813
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3958870001Medicare UPIN