Healthcare Provider Details

I. General information

NPI: 1578714325
Provider Name (Legal Business Name): POWELL VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S ABSAROKA ST
POWELL WY
82435-2708
US

IV. Provider business mailing address

106 S ABSAROKA ST
POWELL WY
82435-2708
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-2020
  • Fax: 307-754-2020
Mailing address:
  • Phone: 307-754-2020
  • Fax: 307-754-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number219T
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number435
License Number StateWY

VIII. Authorized Official

Name: KIMBERLY A MCDOWELL
Title or Position: DOCTOR OF OPTOMETRY
Credential: OD
Phone: 307-754-2020