Healthcare Provider Details

I. General information

NPI: 1942342076
Provider Name (Legal Business Name): CLEAR CREEK VISION CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 N. SUBLETTE
PINEDALE WY
82941
US

IV. Provider business mailing address

376 N. SUBLETTE PO BOX 907
PINEDALE WY
82941
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-2727
  • Fax: 307-367-2727
Mailing address:
  • Phone: 307-367-2727
  • Fax: 307-367-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: LISA E GLENN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 307-367-2727