Provider Demographics
NPI:1639329071
Name:CANADIAN VALLEY VISION CENTER, PC
Entity Type:Organization
Organization Name:CANADIAN VALLEY VISION CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-379-3610
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-0897
Mailing Address - Country:US
Mailing Address - Phone:405-379-3610
Mailing Address - Fax:405-379-2019
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-3229
Practice Address - Country:US
Practice Address - Phone:405-379-3610
Practice Address - Fax:405-379-2019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2576152W00000X, 152WC0802X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6228450001Medicare NSC
OKDO8085Medicare PIN
OKOKB5322Medicare PIN