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General NPI Number Information
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NPI Number | 1194017020
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Entity Type | Organization
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Legal Business Name | GREAT PLAINS VISION CENTER
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Dates
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Enumeration Date | 05/11/2011
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Last Update Date | 09/21/2012
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Provider Practice Location Address
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Address Line | 1418 MAIN ST
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City | WOODWARD
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State | OK
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Zip | 73801-3004
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Country | US
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Telephone | 580-256-6699
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Fax | 580-256-6706
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Provider Business Mailing Address
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Address Line | PO BOX 2484
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City | WOODWARD
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State | OK
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Zip | 73802-2484
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Country | US
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Telephone | 580-256-6699
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Fax | 580-256-6706
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Authorized Official
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Title or Position | OPTOMETRIST / OWNER
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Name | JACOBY J DEWALD
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Credential | OD
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Telephone | 580-256-6699
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2647
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License Number State | OK
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