Provider Demographics
NPI:1194017020
Name:GREAT PLAINS VISION CENTER
Entity Type:Organization
Organization Name:GREAT PLAINS VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOBY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-256-6699
Mailing Address - Street 1:PO BOX 2484
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73802-2484
Mailing Address - Country:US
Mailing Address - Phone:580-256-6699
Mailing Address - Fax:580-256-6706
Practice Address - Street 1:1418 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3004
Practice Address - Country:US
Practice Address - Phone:580-256-6699
Practice Address - Fax:580-256-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA1214Medicare PIN
OK6655850001Medicare NSC