Organization
GLENDIVE EYECARE
Active
Other names
Glendive EyeCare
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GARY D JACOBSEN OD (PRESIDENT)
(406) 365-8231
Entity
Organization
Contact information
Practice address
115 W VALENTINE ST, GLENDIVE, MT 59330-1666
(406) 365-8231
(406) 365-7081
Mailing address
115 W VALENTINE ST, GLENDIVE, MT 59330-1666
(406) 365-8231
(406) 365-7081
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
453
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000026520
BLUE CROSS BLUE SHIELD
MT
01
—
011003935
MEDICARE PTAN
—
05
—
048-0350
—
MT
01
—
410008748
RAILROAD MEDICARE
MT
Enumeration date
03/20/2008
Last updated
07/15/2010
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