Provider Demographics
NPI:1326118688
Name:FREMONT VISION CLINIC INC
Entity Type:Organization
Organization Name:FREMONT VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:AMMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-856-9000
Mailing Address - Street 1:704 E FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4421
Mailing Address - Country:US
Mailing Address - Phone:307-856-9000
Mailing Address - Fax:907-856-9004
Practice Address - Street 1:704 E FREMONT AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4421
Practice Address - Country:US
Practice Address - Phone:307-856-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120883700Medicaid
WY5622650001Medicare NSC
WYU71698Medicare UPIN