Healthcare Provider Details

I. General information

NPI: 1982625703
Provider Name (Legal Business Name): GUTHRIE VISION SOURCE PC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E HARRISON AVE
GUTHRIE OK
73044-4839
US

IV. Provider business mailing address

110 E HARRISON AVE
GUTHRIE OK
73044-4839
US

V. Phone/Fax

Practice location:
  • Phone: 405-282-4396
  • Fax: 405-282-8298
Mailing address:
  • Phone: 405-282-4396
  • Fax: 405-282-8298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateOK

VIII. Authorized Official

Name: MICHAEL E. BENNETT
Title or Position: PRESIDENT
Credential: O.D.
Phone: 405-282-4396