Healthcare Provider Details

I. General information

NPI: 1992957252
Provider Name (Legal Business Name): PERALA ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6207 MISSILE DR BUILDING 722
FT WARREN AFB WY
82005-2407
US

IV. Provider business mailing address

PO BOX 21676
CHEYENNE WY
82003-7031
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-1369
  • Fax: 307-632-2161
Mailing address:
  • Phone: 307-632-1369
  • Fax: 307-632-2161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA S GREEN
Title or Position: MANAGER
Credential: ABOC, FNAO
Phone: 307-632-1369