=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831768779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEVI RYAN BLACK OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2021
-----------------------------------------------------
Last Update Date | 06/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 MAIN ST SW
-----------------------------------------------------
City | RONAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59864-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-676-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 MAIN ST SW
-----------------------------------------------------
City | RONAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59864-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-676-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT-OPT-LIC-4214
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------