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NPI Code Detail

MEDICARE: KATRAE MJ LLC

MEDICARE: KATRAE MJ LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist299TWY

General Provider Information

NPI Number : 1003357153
Entity Type Code : Organization
Provider Name (Legal Business Name) : KATRAE MJ LLC
Provider Business Mailing Address
First Line : 1526 CENTENNIAL CT
Second Line :
City : CASPER
State : WY
Zip : 82609-7304
Country : US
Telephone Number : 307-237-6025
Fax Number : 307-337-3462
Provider Business Practice Location Address
First Line : 1526 CENTENNIAL CT
Second Line :
City : CASPER
State : WY
Zip : 82609-7304
Country : US
Telephone Number : 307-237-6025
Fax Number : 307-337-3462
Authorized Official
Title or Position : OPTOMETRIST
Name : DR. LEVI M PORTER
Credential : O.D.
Telephone Number : 503-504-6941
Provider Enumeration Date : 03/09/2017
Last Update Date : 03/09/2017

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Directions to “KATRAE MJ LLC ” Practice Location

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