Healthcare Provider Details

I. General information

NPI: 1639440019
Provider Name (Legal Business Name): VALLEY VISION CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S. MAIN ST.
LYMAN WY
82937
US

IV. Provider business mailing address

106 S. MAIN ST.
LYMAN WY
82937
US

V. Phone/Fax

Practice location:
  • Phone: 307-787-6123
  • Fax: 307-787-3351
Mailing address:
  • Phone: 307-787-6123
  • Fax: 307-787-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number336T
License Number StateWY

VIII. Authorized Official

Name: DR. TRAVIS JOHN SHELTON
Title or Position: PRESIDENT
Credential: O.D
Phone: 307-787-6123