Provider Demographics
NPI:1477680791
Name:LANDER VISION CENTER, PC
Entity Type:Organization
Organization Name:LANDER VISION CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WEIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-332-2020
Mailing Address - Street 1:556 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3032
Mailing Address - Country:US
Mailing Address - Phone:307-332-5718
Mailing Address - Fax:
Practice Address - Street 1:556 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3032
Practice Address - Country:US
Practice Address - Phone:307-332-2020
Practice Address - Fax:307-332-5718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY134T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106723100Medicaid
WY0676200001Medicare NSC