Provider Demographics
NPI:1760655054
Name:POWDER HORN EYE CARE, LLC
Entity Type:Organization
Organization Name:POWDER HORN EYE CARE, LLC
Other - Org Name:WYOMING EYE ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:B
Authorized Official - Last Name:WHITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-439-0100
Mailing Address - Street 1:4621 SW WYOMING BLVD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6702
Mailing Address - Country:US
Mailing Address - Phone:307-439-0100
Mailing Address - Fax:307-439-1062
Practice Address - Street 1:4621 SW WYOMING BLVD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-6702
Practice Address - Country:US
Practice Address - Phone:307-439-0100
Practice Address - Fax:307-439-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY282T261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY155826900Medicaid