Healthcare Provider Details

I. General information

NPI: 1932389145
Provider Name (Legal Business Name): SHELLY RICE OD PC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 E CHEROKEE ST
WAGONER OK
74467-4710
US

IV. Provider business mailing address

512 E CHEROKEE ST
WAGONER OK
74467-4710
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-4775
  • Fax: 918-485-7611
Mailing address:
  • Phone: 918-485-4775
  • Fax: 918-485-7611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2284
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2284
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2284
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2284
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2284
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2284
License Number StateOK
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number2284
License Number StateOK
# 8
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2284
License Number StateOK

VIII. Authorized Official

Name: SHELLY DEANN RICE
Title or Position: OWNER
Credential: OD
Phone: 918-485-4775