Provider Demographics
NPI:1265780761
Name:EYECARE OF WESTERN OKLAHOMA PC
Entity type:Organization
Organization Name:EYECARE OF WESTERN OKLAHOMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLBY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-225-1980
Mailing Address - Street 1:800 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-3414
Mailing Address - Country:US
Mailing Address - Phone:580-225-1978
Mailing Address - Fax:580-225-8648
Practice Address - Street 1:800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-3414
Practice Address - Country:US
Practice Address - Phone:580-225-1978
Practice Address - Fax:580-225-8648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6964970001Medicare NSC