Provider Demographics
NPI:1528218260
Name:SANDROCK VISION, LLC
Entity Type:Organization
Organization Name:SANDROCK VISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SKEETER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SHOULTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-340-0700
Mailing Address - Street 1:3107 GOLDENROD AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-2287
Mailing Address - Country:US
Mailing Address - Phone:307-340-0700
Mailing Address - Fax:
Practice Address - Street 1:802 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:LUSK
Practice Address - State:WY
Practice Address - Zip Code:82225-0000
Practice Address - Country:US
Practice Address - Phone:307-340-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY317T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW23355Medicare PIN