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General NPI Number Information
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NPI Number | 1902000904
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Entity Type | Organization
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Legal Business Name | FAMILY VISION CARE OF PONCA CITY
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Dates
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Enumeration Date | 06/13/2007
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Last Update Date | 12/30/2016
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Provider Practice Location Address
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Address Line | 1619 N 5TH ST
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City | PONCA CITY
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State | OK
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Zip | 74601-2703
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Country | US
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Telephone | 580-762-5700
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Fax | 580-765-3022
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Provider Business Mailing Address
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Address Line | 1619 N 5TH ST
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City | PONCA CITY
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State | OK
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Zip | 74601-2703
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Country | US
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Telephone | 580-762-5700
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Fax | 580-765-3022
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Authorized Official
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Title or Position | OPTOMETRIST OWNER
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Name | DR. KELLY C CAMPBELL
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Credential | O.D.
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Telephone | 580-762-5700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | OK2144
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | OK2144
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OK2144
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License Number State | OK
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