Provider Demographics
NPI:1336355627
Name:HEART MOUNTAIN EYECARE GROUP
Entity Type:Organization
Organization Name:HEART MOUNTAIN EYECARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:GREG
Authorized Official - Last Name:TOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-754-7151
Mailing Address - Street 1:PO BOX 231
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-0231
Mailing Address - Country:US
Mailing Address - Phone:307-754-7151
Mailing Address - Fax:307-754-4261
Practice Address - Street 1:255 W 3RD ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2321
Practice Address - Country:US
Practice Address - Phone:307-754-7151
Practice Address - Fax:307-754-4261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYDB5764OtherPALMETTO GBA
WY120171900Medicaid
WY05644001OtherBCBS OF WYOMING
WYDB5764OtherPALMETTO GBA
WYW10319Medicare PIN