=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184785867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN OKLAHOMA EYE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 12/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 W 3RD ST
-----------------------------------------------------
City | SULPHUR
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73086-4801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-622-2020
-----------------------------------------------------
Fax | 580-622-3213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 W 3RD ST PO BOX 499
-----------------------------------------------------
City | SULPHUR
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73086-4801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-622-2020
-----------------------------------------------------
Fax | 580-622-3213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE CLERK
-----------------------------------------------------
Name | MRS. KRISTY MARIE CAIN
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 580-622-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------