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General NPI Number Information
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NPI Number | 1982625703
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Entity Type | Organization
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Legal Business Name | GUTHRIE VISION SOURCE PC, INC.
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 02/04/2008
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Provider Practice Location Address
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Address Line | 110 E HARRISON AVE
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City | GUTHRIE
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State | OK
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Zip | 73044-4839
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Country | US
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Telephone | 405-282-4396
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Fax | 405-282-8298
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Provider Business Mailing Address
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Address Line | 110 E HARRISON AVE
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City | GUTHRIE
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State | OK
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Zip | 73044-4839
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Country | US
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Telephone | 405-282-4396
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Fax | 405-282-8298
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL E. BENNETT
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Credential | O.D.
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Telephone | 405-282-4396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State | OK
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Taxonomy #2
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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 | OK
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