Provider Demographics
NPI:1609882810
Name:LAGRECA EYE CLINIC PC
Entity type:Organization
Organization Name:LAGRECA EYE CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAGRECA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-252-6608
Mailing Address - Street 1:2475 VILLAGE LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-2497
Mailing Address - Country:US
Mailing Address - Phone:406-252-6608
Mailing Address - Fax:406-252-6600
Practice Address - Street 1:2475 VILLAGE LN
Practice Address - Street 2:SUITE 202
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-2497
Practice Address - Country:US
Practice Address - Phone:406-252-6608
Practice Address - Fax:406-252-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X
MT10825261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
105765101OtherWORKERS COMP FIC
MT000060752OtherBCBS
MT490005544OtherRAILROAD MEDICARE
MT0000099920OtherBCBS
104306400OtherWORKERS COMP REG
WY311774OtherBCBS
MT0351254Medicaid
WY311773OtherBCBS
WY311774OtherBCBS
MTM000005709Medicare PIN
MT180044575Medicare PIN