Healthcare Provider Details

I. General information

NPI: 1225183957
Provider Name (Legal Business Name): BE THOU MY VISION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E BROADWAY
FAIRVIEW OK
73737-2124
US

IV. Provider business mailing address

111 E BROADWAY
FAIRVIEW OK
73737-2124
US

V. Phone/Fax

Practice location:
  • Phone: 580-227-4878
  • Fax: 580-227-4666
Mailing address:
  • Phone: 580-227-4878
  • Fax: 580-227-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number973
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number973
License Number StateOK

VIII. Authorized Official

Name: BLAKE CARLISLE
Title or Position: PRESIDENT
Credential: OD
Phone: 580-227-4878