=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740222512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL C COTTRELL O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 COBURN AVE
-----------------------------------------------------
City | WORLAND
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82401-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-347-6141
-----------------------------------------------------
Fax | 307-347-6142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2
-----------------------------------------------------
City | WORLAND
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82401-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-347-6141
-----------------------------------------------------
Fax | 307-347-6142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 255T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------