Provider Demographics
NPI:1982749362
Name:HAVRE OPTOMETRIC CLINIC, PLLP
Entity Type:Organization
Organization Name:HAVRE OPTOMETRIC CLINIC, PLLP
Other - Org Name:HAVRE OPTOMETRIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAFLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-265-1231
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-0551
Mailing Address - Country:US
Mailing Address - Phone:406-265-1231
Mailing Address - Fax:406-265-1603
Practice Address - Street 1:416 3RD AVE
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3914
Practice Address - Country:US
Practice Address - Phone:406-265-1231
Practice Address - Fax:406-265-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
MT332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0374180001Medicare NSC
MT000008975Medicare PIN