Healthcare Provider Details

I. General information

NPI: 1679573380
Provider Name (Legal Business Name): RANDY E WADDELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 GREYBULL AVE
GREYBULL WY
82426-2037
US

IV. Provider business mailing address

426 GREYBULL AVE
GREYBULL WY
82426-2037
US

V. Phone/Fax

Practice location:
  • Phone: 307-765-2998
  • Fax: 307-765-2614
Mailing address:
  • Phone: 307-765-2998
  • Fax: 307-765-2614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number133T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: