Provider Demographics
NPI:1750428728
Name:ULTIMATE VISION, PLLC
Entity type:Organization
Organization Name:ULTIMATE VISION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-324-0001
Mailing Address - Street 1:334 S MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6703
Mailing Address - Country:US
Mailing Address - Phone:405-324-0001
Mailing Address - Fax:405-324-0015
Practice Address - Street 1:334 S MUSTANG RD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6703
Practice Address - Country:US
Practice Address - Phone:405-324-0001
Practice Address - Fax:405-324-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
200522088Medicare PIN
5323620001Medicare NSC