Healthcare Provider Details

I. General information

NPI: 1063764173
Provider Name (Legal Business Name): MISSION VALLEY EYE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 MAIN ST SW
RONAN MT
59864-2738
US

IV. Provider business mailing address

417 MAIN ST SW
RONAN MT
59864-2738
US

V. Phone/Fax

Practice location:
  • Phone: 406-676-8921
  • Fax: 406-676-3938
Mailing address:
  • Phone: 406-676-8921
  • Fax: 406-676-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARCUS A SIMONICH
Title or Position: OWNER/DOCTOR
Credential: O.D.
Phone: 406-676-8921