Provider Demographics
NPI:1831215862
Name:MILES CITY VISION CLINIC PC
Entity type:Organization
Organization Name:MILES CITY VISION CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:LUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD OPTOMETRIST
Authorized Official - Phone:406-234-7426
Mailing Address - Street 1:PO BOX 1924
Mailing Address - Street 2:
Mailing Address - City:COLSTRIP
Mailing Address - State:MT
Mailing Address - Zip Code:59323-1924
Mailing Address - Country:US
Mailing Address - Phone:406-748-3290
Mailing Address - Fax:406-748-3301
Practice Address - Street 1:6216 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLSTRIP
Practice Address - State:MT
Practice Address - Zip Code:59323-1924
Practice Address - Country:US
Practice Address - Phone:406-748-3290
Practice Address - Fax:406-748-3301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILES CITY VISION CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-21
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT372152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0482807Medicaid
MTT89256Medicare UPIN
MT000025113Medicare PIN
MT0482807Medicaid