Healthcare Provider Details

I. General information

NPI: 1407130313
Provider Name (Legal Business Name): CARLISLE VISION CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 AVENUE A
BEAVER OK
73932-3101
US

IV. Provider business mailing address

712 AVENUE A
BEAVER OK
73932-3101
US

V. Phone/Fax

Practice location:
  • Phone: 580-625-2020
  • Fax: 580-625-2021
Mailing address:
  • Phone: 580-625-2020
  • Fax: 580-625-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2685
License Number StateOK

VIII. Authorized Official

Name: DR. TREY DEAN CARLISLE
Title or Position: OWNER
Credential: O.D.
Phone: 580-748-0693