Provider Demographics
NPI:1083837926
Name:HERITAGE EYE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:HERITAGE EYE SURGERY CENTER, LLC
Other - Org Name:PRECISION VISION SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PICKARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-733-4545
Mailing Address - Street 1:6922 S. WESTERN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1890
Mailing Address - Country:US
Mailing Address - Phone:405-733-4545
Mailing Address - Fax:405-733-1239
Practice Address - Street 1:6922 S. WESTERN
Practice Address - Street 2:SUITE 102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1890
Practice Address - Country:US
Practice Address - Phone:405-733-4545
Practice Address - Fax:405-733-1239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0019261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734320AMedicaid
OK100734320AMedicaid
OKC94585Medicare UPIN