Healthcare Provider Details

I. General information

NPI: 1780274506
Provider Name (Legal Business Name): JEC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W KENT AVE STE 101
MISSOULA MT
59801-6609
US

IV. Provider business mailing address

409 AGNES AVE
MISSOULA MT
59801-8746
US

V. Phone/Fax

Practice location:
  • Phone: 406-272-0453
  • Fax: 406-221-3754
Mailing address:
  • Phone: 406-546-6854
  • Fax: 406-221-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RACHAEL M BEATTY
Title or Position: OPTOMETRIST/OWNER
Credential: OD
Phone: 406-272-0453