=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770208431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CAAN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2022
-----------------------------------------------------
Last Update Date | 11/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6303 NW 23RD ST
-----------------------------------------------------
City | BETHANY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73008-5931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-782-0300
-----------------------------------------------------
Fax | 405-782-0302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3908 PRESTON CT
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73072-5019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-993-0575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. CHRIS B BOALDIN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 316-993-0575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------