=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831318633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CARE ASSOCIATES OF YUKON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 12/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1604 PROFESSIONAL CIR
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-354-3624
-----------------------------------------------------
Fax | 405-350-7512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1604 PROFESSIONAL CIR
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-354-3624
-----------------------------------------------------
Fax | 405-350-7512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON MYERS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 405-354-3624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1109
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------