Provider Demographics
NPI:1033302856
Name:YOUR FAMILY OPTICAL
Entity Type:Organization
Organization Name:YOUR FAMILY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:307-638-0260
Mailing Address - Street 1:4214 CHEYENNE ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1923
Mailing Address - Country:US
Mailing Address - Phone:307-638-0260
Mailing Address - Fax:307-514-4348
Practice Address - Street 1:4214 CHEYENNE ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1923
Practice Address - Country:US
Practice Address - Phone:307-638-0260
Practice Address - Fax:307-514-4348
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUR FAMILY OPTICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty