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General NPI Number Information
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NPI Number | 1003036716
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Entity Type | Organization
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Legal Business Name | POTEAU VISION SOURCE, PC
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 2203-B N. BROADWAY
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City | POTEAU
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State | OK
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Zip | 74953
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Country | US
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Telephone | 918-649-0524
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Fax | 918-649-0891
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Provider Business Mailing Address
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Address Line | 2203-B N. BROADWAY
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City | POTEAU
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State | OK
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Zip | 74953
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Country | US
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Telephone | 918-649-0524
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Fax | 918-649-0891
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TAMATHA KAY HOLT
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Credential | O.D.
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Telephone | 918-649-0524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 2148
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License Number State | OK
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