=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093726796
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKY MOUNTAIN EYE SURGERY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 04/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 WEST KENT
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-541-3883
-----------------------------------------------------
Fax | 406-541-3884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 W KENT AVE
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-6772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-541-3806
-----------------------------------------------------
Fax | 406-541-3811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RYAN L PETERSON
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 406-541-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 11789
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------