Provider Demographics
NPI:1528251832
Name:KOOTENAI VISION CENTERS PC
Entity type:Organization
Organization Name:KOOTENAI VISION CENTERS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-293-4136
Mailing Address - Street 1:422 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2132
Mailing Address - Country:US
Mailing Address - Phone:406-293-4136
Mailing Address - Fax:406-293-2033
Practice Address - Street 1:422 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2132
Practice Address - Country:US
Practice Address - Phone:406-293-4136
Practice Address - Fax:406-293-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0677320002Medicare NSC