Provider Demographics
NPI:1033313754
Name:TAHLEQUAH FAMILY VISION CLINIC, PLLC
Entity Type:Organization
Organization Name:TAHLEQUAH FAMILY VISION CLINIC, PLLC
Other - Org Name:TAHLEQUAH FAMILY VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:GEAN
Authorized Official - Last Name:TEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-456-2250
Mailing Address - Street 1:681 W CHOCTAW ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3711
Mailing Address - Country:US
Mailing Address - Phone:918-456-2250
Mailing Address - Fax:918-456-2251
Practice Address - Street 1:681 W CHOCTAW ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3711
Practice Address - Country:US
Practice Address - Phone:918-456-2250
Practice Address - Fax:918-456-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK 2111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU46861Medicare UPIN
OK6171700001Medicare NSC
OK447726348Medicare PIN