Healthcare Provider Details

I. General information

NPI: 1992802920
Provider Name (Legal Business Name): WILLCOCKSON EYE ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W 3RD ST
YANKTON SD
57078-4201
US

IV. Provider business mailing address

415 W 3RD ST
YANKTON SD
57078-4201
US

V. Phone/Fax

Practice location:
  • Phone: 605-665-9638
  • Fax: 605-665-0526
Mailing address:
  • Phone: 605-665-9638
  • Fax: 605-665-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0017
License Number StateSD

VIII. Authorized Official

Name: MR. LEE ALAN GASS
Title or Position: ADMINISTRATOR
Credential:
Phone: 605-665-9638