Healthcare Provider Details

I. General information

NPI: 1235381401
Provider Name (Legal Business Name): GREAT NORTHERN EYE CARE AND STUMPTOWN SPECTACLES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2008
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6414 US HIGHWAY 93 S
WHITEFISH MT
59937-8237
US

IV. Provider business mailing address

6414 US HIGHWAY 93 S
WHITEFISH MT
59937-8237
US

V. Phone/Fax

Practice location:
  • Phone: 406-862-6123
  • Fax:
Mailing address:
  • Phone: 406-862-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number639
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number639 OPT
License Number StateMT

VIII. Authorized Official

Name: EVA BUKER
Title or Position: OPTOMETRIST/OWNER
Credential: O.D.
Phone: 406-253-0086