Provider Demographics
NPI:1942342076
Name:CLEAR CREEK VISION CARE, P.C.
Entity Type:Organization
Organization Name:CLEAR CREEK VISION CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-367-2727
Mailing Address - Street 1:376 N. SUBLETTE
Mailing Address - Street 2:PO BOX 907
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941
Mailing Address - Country:US
Mailing Address - Phone:307-367-2727
Mailing Address - Fax:307-367-2727
Practice Address - Street 1:376 N. SUBLETTE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-2727
Practice Address - Fax:307-367-2727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1150380001Medicare NSC
WY307257Medicare ID - Type Unspecified