1730204165 NPI number — HERITAGE PARK EYE CARE CENTER

Table of content: (NPI 1730204165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730204165 NPI number — HERITAGE PARK EYE CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE PARK EYE CARE CENTER
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:
VISION SOURCE MIDWEST CITY
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:
1730204165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2008 S. POST ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDWEST CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-732-2277
Provider Business Mailing Address Fax Number:
405-737-4776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2008 S. POST ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDWEST CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-732-2277
Provider Business Practice Location Address Fax Number:
405-737-4776
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTENSEN
Authorized Official First Name:
COREY
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
405-732-2277

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  2413 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CS4518 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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