Provider Demographics
NPI:1841461563
Name:GLENDIVE EYECARE
Entity type:Organization
Organization Name:GLENDIVE EYECARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-365-8231
Mailing Address - Street 1:115 W VALENTINE ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1666
Mailing Address - Country:US
Mailing Address - Phone:406-365-8231
Mailing Address - Fax:406-365-7081
Practice Address - Street 1:115 W VALENTINE ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1666
Practice Address - Country:US
Practice Address - Phone:406-365-8231
Practice Address - Fax:406-365-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT453261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000026520OtherBLUE CROSS BLUE SHIELD
011003935OtherMEDICARE PTAN
MT048-0350Medicaid
MT410008748OtherRAILROAD MEDICARE
MTT89255Medicare UPIN
011003935OtherMEDICARE PTAN
MT0211400001Medicare NSC