=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073505699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUBOIS VISION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2005
-----------------------------------------------------
Last Update Date | 07/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 W RAMSHORN DR
-----------------------------------------------------
City | DUBOIS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82513-0480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-455-2125
-----------------------------------------------------
Fax | 307-856-8548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 480
-----------------------------------------------------
City | DUBOIS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82513-0480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-455-2125
-----------------------------------------------------
Fax | 307-856-8548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | MR. BRIAN J BALLARD
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 307-856-9451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 118T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------