Provider Demographics
NPI:1558615179
Name:CHEYENNE VISION CLINIC P.C.
Entity Type:Organization
Organization Name:CHEYENNE VISION CLINIC P.C.
Other - Org Name:LARAMIE VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-638-6610
Mailing Address - Street 1:1200 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3230
Mailing Address - Country:US
Mailing Address - Phone:307-638-6610
Mailing Address - Fax:
Practice Address - Street 1:408 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3614
Practice Address - Country:US
Practice Address - Phone:307-721-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty