MEDICARE: HEART MOUNTAIN EYECARE GROUP

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
1	152WC0802X	Corneal and Contact Management Optometrist		WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DB5764	OTHER	WY	PALMETTO GBA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	05644001	OTHER	WY	BCBS OF WYOMING

General Provider Information

NPI Number	:	1336355627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART MOUNTAIN EYECARE GROUP

Provider Business Mailing Address
First Line	:	PO BOX 231
Second Line	:
City	:	POWELL
State	:	WY
Zip	:	82435-0231
Country	:	US
Telephone Number	:	307-754-7151
Fax Number	:	307-754-4261

Provider Business Practice Location Address
First Line	:	255 W 3RD ST
Second Line	:
City	:	POWELL
State	:	WY
Zip	:	82435-2321
Country	:	US
Telephone Number	:	307-754-7151
Fax Number	:	307-754-4261

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSEPH GREG TOLAND
Credential	:
Telephone Number	:	307-754-7151

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	12/11/2008

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