Healthcare Provider Details

I. General information

NPI: 1144759945
Provider Name (Legal Business Name): VANCE THOMPSON VISION MT PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 N 22ND AVE
BOZEMAN MT
59718-7020
US

IV. Provider business mailing address

3101 W 57TH ST
SIOUX FALLS SD
57108-3162
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-3937
  • Fax:
Mailing address:
  • Phone: 605-361-3937
  • Fax: 605-371-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMED-PHYS-LIC-57511
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT JENSEN
Title or Position: CEO
Credential:
Phone: 605-361-3937