Healthcare Provider Details

I. General information

NPI: 1205977394
Provider Name (Legal Business Name): NORTH EAST FAMILY EYECARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DALLAS ST
TALIHINA OK
74571-2402
US

IV. Provider business mailing address

200 DALLAS ST
TALIHINA OK
74571-2402
US

V. Phone/Fax

Practice location:
  • Phone: 903-244-2889
  • Fax: 918-567-3240
Mailing address:
  • Phone: 903-244-2889
  • Fax: 918-567-3240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number6474TG
License Number StateTX

VIII. Authorized Official

Name: DR. OLIN W FENTON
Title or Position: OWNER DOCTOR
Credential: OD
Phone: 903-244-2889