Healthcare Provider Details

I. General information

NPI: 1891850707
Provider Name (Legal Business Name): GILLETTE OPTOMETRIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 4J CT
GILLETTE WY
82716-4135
US

IV. Provider business mailing address

609 4J CT
GILLETTE WY
82716-4135
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-2020
  • Fax: 307-682-5656
Mailing address:
  • Phone: 307-682-2020
  • Fax: 307-682-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number93-T
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number288-T
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number263-T
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number142-T
License Number StateWY

VIII. Authorized Official

Name: DR. ROGER L JORDAN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 307-682-2020