Provider Demographics
NPI:1528210515
Name:EYE CARE ASSOCIATES OF WYOMING, P.C.
Entity Type:Organization
Organization Name:EYE CARE ASSOCIATES OF WYOMING, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-686-2010
Mailing Address - Street 1:312 E LAKEWAY RD
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6329
Mailing Address - Country:US
Mailing Address - Phone:307-686-2010
Mailing Address - Fax:307-686-1052
Practice Address - Street 1:312 E LAKEWAY RD
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6329
Practice Address - Country:US
Practice Address - Phone:307-686-2010
Practice Address - Fax:307-686-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY191T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY6199120001Medicare NSC