Provider Demographics
NPI:1326459835
Name:JACOB G. DESPAIN OD PC
Entity Type:Organization
Organization Name:JACOB G. DESPAIN OD PC
Other - Org Name:FAMILY VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:G
Authorized Official - Last Name:DESPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-587-2404
Mailing Address - Street 1:426 NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-1916
Mailing Address - Country:US
Mailing Address - Phone:307-548-7450
Mailing Address - Fax:307-548-7596
Practice Address - Street 1:426 NEVADA AVE
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-1916
Practice Address - Country:US
Practice Address - Phone:307-548-7450
Practice Address - Fax:307-548-7596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY327T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty