Provider Demographics
NPI:1316121627
Name:EYES ON MAIN INCORPORATED
Entity type:Organization
Organization Name:EYES ON MAIN INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SQUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-586-2173
Mailing Address - Street 1:1425 W MAIN ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3283
Mailing Address - Country:US
Mailing Address - Phone:406-586-2173
Mailing Address - Fax:
Practice Address - Street 1:1425 W MAIN ST
Practice Address - Street 2:UNIT B
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3283
Practice Address - Country:US
Practice Address - Phone:406-586-2173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000028361OtherBCBS OF MONTANA
MT0483752Medicaid
1982766747OtherINDIVIDUAL NPI NUMBER
MT000085167OtherMEDICARE GROUP PIN
MTMS2466476OtherDEA NUMBER
MTMS2466476OtherDEA NUMBER
MT0483752Medicaid
000025160Medicare PIN
MT0483752Medicaid
MT=========OtherEIN