Provider Demographics
NPI:1093966798
Name:RIVERSIDE EYE CLINIC
Entity Type:Organization
Organization Name:RIVERSIDE EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHEFF-PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-296-4733
Mailing Address - Street 1:524 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4137
Mailing Address - Country:US
Mailing Address - Phone:918-296-4733
Mailing Address - Fax:918-296-4734
Practice Address - Street 1:524 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4137
Practice Address - Country:US
Practice Address - Phone:918-296-4733
Practice Address - Fax:918-296-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2205152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3171770001OtherDMERC
OK200004890AMedicaid
OK3171770001OtherDMERC
OKU22150Medicare UPIN