Provider Demographics
NPI:1578714325
Name:POWELL VISION LLC
Entity Type:Organization
Organization Name:POWELL VISION LLC
Other - Org Name:POWELL VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-754-2020
Mailing Address - Street 1:106 S ABSAROKA ST
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2708
Mailing Address - Country:US
Mailing Address - Phone:307-754-2020
Mailing Address - Fax:307-754-2020
Practice Address - Street 1:106 S ABSAROKA ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2708
Practice Address - Country:US
Practice Address - Phone:307-754-2020
Practice Address - Fax:307-754-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY219T152W00000X
WY435225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY126912700Medicaid