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General NPI Number Information
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NPI Number | 1841461563
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Entity Type | Organization
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Legal Business Name | GLENDIVE EYECARE
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Dates
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Enumeration Date | 03/20/2008
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Last Update Date | 07/15/2010
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Provider Practice Location Address
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Address Line | 115 W VALENTINE ST
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City | GLENDIVE
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State | MT
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Zip | 59330-1666
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Country | US
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Telephone | 406-365-8231
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Fax | 406-365-7081
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Provider Business Mailing Address
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Address Line | 115 W VALENTINE ST
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City | GLENDIVE
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State | MT
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Zip | 59330-1666
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Country | US
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Telephone | 406-365-8231
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Fax | 406-365-7081
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY D JACOBSEN
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Credential | OD
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Telephone | 406-365-8231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 453
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License Number State | MT
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