1336212158 NPI number — LOWER VALLEY VISION CLINIC INC

Table of content: (NPI 1336212158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336212158 NPI number — LOWER VALLEY VISION CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOWER VALLEY VISION CLINIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336212158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THAYNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83127-0800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-883-4678
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
491 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
THAYNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83127-9768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-883-4678
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROG
Authorized Official First Name:
LUKE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
307-883-4678

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  296T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 296T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 121600700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 313773 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 5646844 . This is a "CBSA" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 285174 . This is a "ALTIUS HEALTH PLANS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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