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General NPI Number Information
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NPI Number | 1770823072
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Entity Type | Organization
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Legal Business Name | VISION SOURCE ALTUS PLLC
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Dates
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Enumeration Date | 02/22/2013
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Last Update Date | 01/03/2014
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Provider Practice Location Address
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Address Line | 112 VAL VERDE ST
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City | ALTUS
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State | OK
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Zip | 73521-1190
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Country | US
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Telephone | 580-482-0051
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Fax | 580-482-7746
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Provider Business Mailing Address
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Address Line | 112 VAL VERDE ST STE C
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City | ALTUS
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State | OK
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Zip | 73521-1190
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Country | US
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Telephone | 580-482-0051
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Fax | 580-482-7746
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Authorized Official
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Title or Position | OWNER -OPTOMETRIST
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Name | DR. STEVEN A. GIFFORD
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Credential | O.D.
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Telephone | 580-482-0051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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