Provider Demographics
NPI:1972645315
Name:WYOMING EYE CARE INC PC
Entity Type:Organization
Organization Name:WYOMING EYE CARE INC PC
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:307-733-4905
Mailing Address - Street 1:PO BOX 8460
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8460
Mailing Address - Country:US
Mailing Address - Phone:307-733-4905
Mailing Address - Fax:307-733-4906
Practice Address - Street 1:110 BUFFALO WAY ST A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-733-4905
Practice Address - Fax:307-733-4906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY03628OtherBCBS
WY3937060001Medicare NSC
WYW308381Medicare PIN