Healthcare Provider Details

I. General information

NPI: 1336212158
Provider Name (Legal Business Name): LOWER VALLEY VISION CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 N MAIN ST SUITE A
THAYNE WY
83127-9768
US

IV. Provider business mailing address

PO BOX 800
THAYNE WY
83127-0800
US

V. Phone/Fax

Practice location:
  • Phone: 307-883-4678
  • Fax:
Mailing address:
  • Phone: 307-883-4678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number296T
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number296T
License Number StateWY

VIII. Authorized Official

Name: DR. LUKE BROG
Title or Position: PRESIDENT
Credential: O.D.
Phone: 307-883-4678