Provider Demographics
NPI:1003357153
Name:KATRAE MJ LLC
Entity Type:Organization
Organization Name:KATRAE MJ LLC
Other - Org Name:WIND CITY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:M
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-504-6941
Mailing Address - Street 1:1526 CENTENNIAL CT
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-7304
Mailing Address - Country:US
Mailing Address - Phone:307-237-6025
Mailing Address - Fax:307-337-3462
Practice Address - Street 1:1526 CENTENNIAL CT
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-7304
Practice Address - Country:US
Practice Address - Phone:307-237-6025
Practice Address - Fax:307-337-3462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY299T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty