=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891850707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILLETTE OPTOMETRIC CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 04/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 4J CT
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-682-2020
-----------------------------------------------------
Fax | 307-682-5656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 609 4J CT
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-682-2020
-----------------------------------------------------
Fax | 307-682-5656
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROGER L JORDAN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 307-682-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 93-T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 288-T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | 263-T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 142-T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------