Provider Demographics
NPI:1700055951
Name:KISTER EYECARE, PC
Entity Type:Organization
Organization Name:KISTER EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KISTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-856-6531
Mailing Address - Street 1:400 E ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4413
Mailing Address - Country:US
Mailing Address - Phone:307-856-6531
Mailing Address - Fax:307-856-1306
Practice Address - Street 1:400 E ADAMS AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4413
Practice Address - Country:US
Practice Address - Phone:307-856-6531
Practice Address - Fax:307-856-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY115T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104032400Medicaid
WY4590585OtherMEDICARE
WY1897-001OtherBCBS
WY104032400Medicaid
WY4590585OtherMEDICARE