Provider Demographics
NPI:1740349554
Name:FAMILY VISION CENTER PC
Entity type:Organization
Organization Name:FAMILY VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-634-4232
Mailing Address - Street 1:400 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4616
Mailing Address - Country:US
Mailing Address - Phone:307-634-4232
Mailing Address - Fax:307-778-8429
Practice Address - Street 1:400 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4616
Practice Address - Country:US
Practice Address - Phone:307-634-4232
Practice Address - Fax:307-778-8429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYCG2259OtherRR MEDICARE
WY109909400Medicaid
WY0599050001Medicare NSC