=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649588419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENVISION MEDICAL & SURGICAL EYE CARE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2010
-----------------------------------------------------
Last Update Date | 01/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 E CLARK BASS BLVD SUITE 204
-----------------------------------------------------
City | MCALESTER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74501-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-421-6656
-----------------------------------------------------
Fax | 918-421-6659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 E CLARK BASS BLVD SUITE 204
-----------------------------------------------------
City | MCALESTER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74501-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-421-6656
-----------------------------------------------------
Fax | 918-421-6659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO
-----------------------------------------------------
Name | MRS. MIRANDA RENFROW
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 918-421-6656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 4949
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------