Provider Demographics
NPI:1447422795
Name:LAVALLEY VISION CARE, INC
Entity Type:Organization
Organization Name:LAVALLEY VISION CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-652-2345
Mailing Address - Street 1:900 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-4252
Mailing Address - Country:US
Mailing Address - Phone:918-652-2345
Mailing Address - Fax:918-652-2537
Practice Address - Street 1:900 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4252
Practice Address - Country:US
Practice Address - Phone:918-652-2345
Practice Address - Fax:918-652-2537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0643770001Medicare NSC