1487716668 NPI number — SCOTTSBLUFF VISION CLINIC P C

Table of content: (NPI 1487716668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487716668 NPI number — SCOTTSBLUFF VISION CLINIC P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTTSBLUFF VISION CLINIC P C
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:
EASTERN WYOMING EYE CLINIC
Provider Other Organization Name Type Code:
3
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:
1487716668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 COLLEGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRINGTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82240-1517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-532-2060
Provider Business Mailing Address Fax Number:
307-532-5710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TORRINGTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82240-1517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-532-2060
Provider Business Practice Location Address Fax Number:
307-532-5710
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAHONEY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
307-532-2060

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  123T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 193T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 316T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 174T , 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: 102711500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0027001 . This is a "BCBS WY SUBMITTER ID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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