Provider Demographics
NPI:1336212158
Name:LOWER VALLEY VISION CLINIC INC
Entity Type:Organization
Organization Name:LOWER VALLEY VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-883-4678
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-0800
Mailing Address - Country:US
Mailing Address - Phone:307-883-4678
Mailing Address - Fax:
Practice Address - Street 1:491 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127-9768
Practice Address - Country:US
Practice Address - Phone:307-883-4678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY296T152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121600700Medicaid
WY313773OtherBLUE CROSS BLUE SHIELD
WY5646844OtherCBSA
WY285174OtherALTIUS HEALTH PLANS
WY20532Medicare ID - Type Unspecified
WY313773OtherBLUE CROSS BLUE SHIELD
WY5643540001Medicare NSC