1790823300 NPI number — EYE RESTORATION CLINIC

Table of content: (NPI 1790823300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790823300 NPI number — EYE RESTORATION CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE RESTORATION CLINIC
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:
ELSIE M. JOY, B.C.O.
Provider Other Organization Name Type Code:
4
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:
1790823300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4606 S GARNETT RD
Provider Second Line Business Mailing Address:
#302
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74146-5231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-664-6544
Provider Business Mailing Address Fax Number:
918-664-0668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4606 S GARNETT RD
Provider Second Line Business Practice Location Address:
#302
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74146-5231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-664-6544
Provider Business Practice Location Address Fax Number:
918-664-0668
Provider Enumeration Date:
02/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOY
Authorized Official First Name:
ELSIE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OCULARIST
Authorized Official Telephone Number:
918-664-6544

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  NON REQUIRED , 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: 546768030001 . This is a "BLUE LINCS HMO" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 546768030001 . This is a "BCBS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 0259450001 . This is a "RR MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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