Healthcare Provider Details

I. General information

NPI: 1881758332
Provider Name (Legal Business Name): JAMES A BOUCHER & SUE E LOWE PTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S 30TH ST
LARAMIE WY
82070-5143
US

IV. Provider business mailing address

405 S 30TH ST
LARAMIE WY
82070-5143
US

V. Phone/Fax

Practice location:
  • Phone: 307-742-2020
  • Fax:
Mailing address:
  • Phone: 307-742-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number237T
License Number StateWY

VIII. Authorized Official

Name: DR. GARY M POTEET
Title or Position: PARTNER
Credential: OD
Phone: 307-742-2020