Provider Demographics
NPI:1629182167
Name:NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY
Entity Type:Organization
Organization Name:NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-456-5511
Mailing Address - Street 1:1001 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7017
Mailing Address - Country:US
Mailing Address - Phone:918-458-2109
Mailing Address - Fax:918-458-2310
Practice Address - Street 1:301 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-774-1480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier