=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760655054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWDER HORN EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2008
-----------------------------------------------------
Last Update Date | 05/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4621 SW WYOMING BLVD
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82601-6702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-439-0100
-----------------------------------------------------
Fax | 307-439-1062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4621 SW WYOMING BLVD
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82601-6702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-439-0100
-----------------------------------------------------
Fax | 307-439-1062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON B WHITMAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 307-439-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 282T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------