Provider Demographics
NPI:1194908624
Name:MONTANA FAMILY VISION CARE, PC
Entity type:Organization
Organization Name:MONTANA FAMILY VISION CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-542-6382
Mailing Address - Street 1:2829 GREAT NORTHERN LOOP
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1752
Mailing Address - Country:US
Mailing Address - Phone:406-542-6382
Mailing Address - Fax:406-542-4773
Practice Address - Street 1:2829 GREAT NORTHERN LOOP
Practice Address - Street 2:SUITE 100
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1752
Practice Address - Country:US
Practice Address - Phone:406-542-6382
Practice Address - Fax:406-542-4773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT671152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0481423Medicaid
MT82811Medicare PIN
MT6414490001Medicare NSC
MT0481423Medicaid