=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336212158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOWER VALLEY VISION CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 03/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 491 N MAIN ST SUITE A
-----------------------------------------------------
City | THAYNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83127-9768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-883-4678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 800
-----------------------------------------------------
City | THAYNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83127-0800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-883-4678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LUKE BROG
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 307-883-4678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 296T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 296T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------