Provider Demographics
NPI:1073505699
Name:DUBOIS VISION CENTER
Entity Type:Organization
Organization Name:DUBOIS VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-856-9451
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:WY
Mailing Address - Zip Code:82513-0480
Mailing Address - Country:US
Mailing Address - Phone:307-455-2125
Mailing Address - Fax:307-856-8548
Practice Address - Street 1:1203 W RAMSHORN DR
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:WY
Practice Address - Zip Code:82513-0480
Practice Address - Country:US
Practice Address - Phone:307-455-2125
Practice Address - Fax:307-856-8548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY118T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0762340001OtherCIGNA MEDICARE
WY104136300Medicaid
WIT44160Medicare UPIN
WIW307997Medicare ID - Type Unspecified
WY6354490001Medicare NSC