Healthcare Provider Details

I. General information

NPI: 1750426904
Provider Name (Legal Business Name): OWL CREEK VISION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 MAIN ST
LANDER WY
82520-3128
US

IV. Provider business mailing address

278 MAIN ST
LANDER WY
82520-3128
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7284
  • Fax: 307-332-7285
Mailing address:
  • Phone: 307-332-7284
  • Fax: 307-332-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID WAYNE RODGERS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 307-332-7284