Healthcare Provider Details

I. General information

NPI: 1538209390
Provider Name (Legal Business Name): EYE CLINIC OF GREAT FALLS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 CHOUTEAU STREET
FORT BENTON MT
59442
US

IV. Provider business mailing address

PO BOX 249
FORT BENTON MT
59442
US

V. Phone/Fax

Practice location:
  • Phone: 406-622-5449
  • Fax: 406-622-6188
Mailing address:
  • Phone: 406-622-5449
  • Fax: 406-622-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN A KUMM
Title or Position: PARTNER OWNER
Credential: OPTOMETRIST OD
Phone: 406-452-9507