=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417190778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY EYE & VISION CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2009
-----------------------------------------------------
Last Update Date | 04/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 S INDEPENDENCE AVE
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-5624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-242-2020
-----------------------------------------------------
Fax | 580-234-1699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 S INDEPENDENCE AVE
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-5624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-242-2020
-----------------------------------------------------
Fax | 580-234-1699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. LINDA L KRAFT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-242-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 2321
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------