Provider Demographics
NPI:1174962542
Name:ROCKY MOUNTAIN VEIN CLINIC BOZEMAN, INC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN VEIN CLINIC BOZEMAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-252-8346
Mailing Address - Street 1:2820 CENTRAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-8624
Mailing Address - Country:US
Mailing Address - Phone:406-252-8346
Mailing Address - Fax:406-656-8303
Practice Address - Street 1:822 STONERIDGE DR STE 2
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7047
Practice Address - Country:US
Practice Address - Phone:406-252-8346
Practice Address - Fax:406-656-8303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10772174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty