Healthcare Provider Details

I. General information

NPI: 1669465092
Provider Name (Legal Business Name): THERESA J. HAAS O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 18TH ST
CHEYENNE WY
82001-4616
US

IV. Provider business mailing address

400 E 18TH ST
CHEYENNE WY
82001-4616
US

V. Phone/Fax

Practice location:
  • Phone: 307-634-4232
  • Fax: 307-778-8429
Mailing address:
  • Phone: 307-634-4232
  • Fax: 307-778-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number238T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: