Provider Demographics
NPI:1962494690
Name:RIVERTON VISION CENTER P.C.
Entity Type:Organization
Organization Name:RIVERTON VISION CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-856-9451
Mailing Address - Street 1:300 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3545
Mailing Address - Country:US
Mailing Address - Phone:307-856-9451
Mailing Address - Fax:307-856-8548
Practice Address - Street 1:300 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3545
Practice Address - Country:US
Practice Address - Phone:307-856-9451
Practice Address - Fax:307-856-8548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100015200Medicaid
WY0762340001Medicare NSC