Healthcare Provider Details

I. General information

NPI: 1710488275
Provider Name (Legal Business Name): THE EYE SITE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 OKLAHOMA BLVD STE A
ALVA OK
73717-2631
US

IV. Provider business mailing address

502 MYERS DR
ALVA OK
73717-3504
US

V. Phone/Fax

Practice location:
  • Phone: 580-732-2393
  • Fax:
Mailing address:
  • Phone: 580-732-2393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2861
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2861
License Number StateOK

VIII. Authorized Official

Name: DR. CALLIE MOSBURG
Title or Position: OWNER
Credential: OD
Phone: 580-732-2393