Provider Demographics
NPI:1467697862
Name:CHARLES R. VANDERVORT, O.D., P.C.
Entity Type:Organization
Organization Name:CHARLES R. VANDERVORT, O.D., P.C.
Other - Org Name:EYE CARE SPECIALISTS OF GREEN RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDERVORT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-875-4538
Mailing Address - Street 1:665 UINTA DR
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-5031
Mailing Address - Country:US
Mailing Address - Phone:307-875-4538
Mailing Address - Fax:307-875-8997
Practice Address - Street 1:665 UINTA DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5031
Practice Address - Country:US
Practice Address - Phone:307-875-4538
Practice Address - Fax:307-875-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-14
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY101T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0748390001Medicare NSC