Provider Demographics
NPI:1235264185
Name:SPLITROCK VISION CLINIC P C INC
Entity Type:Organization
Organization Name:SPLITROCK VISION CLINIC P C INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-322-9747
Mailing Address - Street 1:404 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-2910
Mailing Address - Country:US
Mailing Address - Phone:307-322-9747
Mailing Address - Fax:307-322-7996
Practice Address - Street 1:404 9TH ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2910
Practice Address - Country:US
Practice Address - Phone:307-322-9747
Practice Address - Fax:307-322-9776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY9424Medicare ID - Type Unspecified
WY9424Medicare PIN