Provider Demographics
NPI:1154655280
Name:ADVANCED EYE CARE, PLLC
Entity Type:Organization
Organization Name:ADVANCED EYE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-427-3937
Mailing Address - Street 1:PO BOX 1075
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-1075
Mailing Address - Country:US
Mailing Address - Phone:918-427-3937
Mailing Address - Fax:918-427-8882
Practice Address - Street 1:311 E RAY FINE BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5160
Practice Address - Country:US
Practice Address - Phone:918-427-3937
Practice Address - Fax:918-427-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6332420001Medicare NSC