=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609882810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGRECA EYE CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 12/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2475 VILLAGE LN SUITE 202
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-252-6608
-----------------------------------------------------
Fax | 406-252-6600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2475 VILLAGE LN SUITE 202
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-252-6608
-----------------------------------------------------
Fax | 406-252-6600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR PRESIDENT
-----------------------------------------------------
Name | DR. BRIAN A LAGRECA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 406-252-6608
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 10825
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------