Healthcare Provider Details

I. General information

NPI: 1902000904
Provider Name (Legal Business Name): FAMILY VISION CARE OF PONCA CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 N 5TH ST
PONCA CITY OK
74601-2703
US

IV. Provider business mailing address

1619 N 5TH ST
PONCA CITY OK
74601-2703
US

V. Phone/Fax

Practice location:
  • Phone: 580-762-5700
  • Fax: 580-765-3022
Mailing address:
  • Phone: 580-762-5700
  • Fax: 580-765-3022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOK2144
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberOK2144
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOK2144
License Number StateOK

VIII. Authorized Official

Name: DR. KELLY C CAMPBELL
Title or Position: OPTOMETRIST OWNER
Credential: O.D.
Phone: 580-762-5700