Provider Demographics
NPI:1689707820
Name:BASIN VISION CENTER, P. C.
Entity Type:Organization
Organization Name:BASIN VISION CENTER, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-587-4206
Mailing Address - Street 1:PO BOX 2810
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2810
Mailing Address - Country:US
Mailing Address - Phone:307-587-4206
Mailing Address - Fax:307-587-5539
Practice Address - Street 1:620 19TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3305
Practice Address - Country:US
Practice Address - Phone:307-587-4206
Practice Address - Fax:307-587-5539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9010OtherPTAN
WY0331670001Medicare NSC