1811348766 NPI number — ENVISION MEDICAL & SURGICAL EYE CARE PC

Table of content: (NPI 1811348766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811348766 NPI number — ENVISION MEDICAL & SURGICAL EYE CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENVISION MEDICAL & SURGICAL EYE CARE PC
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:
1811348766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4926 W KENOSHA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012-8517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-605-7456
Provider Business Mailing Address Fax Number:
918-893-1724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4926 W KENOSHA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74012-8517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-605-7456
Provider Business Practice Location Address Fax Number:
918-893-1724
Provider Enumeration Date:
06/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RENFROW
Authorized Official First Name:
MIRANDA
Authorized Official Middle Name:
KIRSTEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
918-605-7456

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  4949 , 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: OKA102502 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com