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General NPI Number Information
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NPI Number | 1629182167
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Entity Type | Organization
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Legal Business Name | NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 07/08/2008
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Provider Practice Location Address
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Address Line | 301 J T STITES BLVD
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City | SALLISAW
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State | OK
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Zip | 74955-9302
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Country | US
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Telephone | 918-774-1480
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 N GRAND AVE
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City | TAHLEQUAH
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State | OK
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Zip | 74464-7017
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Country | US
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Telephone | 918-458-2109
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Fax | 918-458-2310
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Authorized Official
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Title or Position | DEAN
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Name | DR. GEORGE EDWARD FOSTER
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Credential | O.D.
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Telephone | 918-456-5511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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