Provider Demographics
NPI:1750426904
Name:OWL CREEK VISION CARE
Entity type:Organization
Organization Name:OWL CREEK VISION CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-332-7284
Mailing Address - Street 1:278 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3128
Mailing Address - Country:US
Mailing Address - Phone:307-332-7284
Mailing Address - Fax:307-332-7285
Practice Address - Street 1:278 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3128
Practice Address - Country:US
Practice Address - Phone:307-332-7284
Practice Address - Fax:307-332-7285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124197400Medicaid
WY4721001OtherBCBS OF WY PRACTICE
WY5993950001Medicare NSC
WYW21178Medicare PIN