MEDICARE: VISION THERAPY CENTER 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
1	152WV0400X	Vision Therapy Optometrist

General Provider Information

NPI Number	:	1356991624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISION THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	5734 SHERIDAN LAKE RD STE 202
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8814
Country	:	US
Telephone Number	:	605-342-0258
Fax Number	:	605-342-0209

Provider Business Practice Location Address
First Line	:	5734 SHERIDAN LAKE RD STE 202
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8814
Country	:	US
Telephone Number	:	605-342-0258
Fax Number	:	605-342-0209

Authorized Official
Title or Position	:	CEO
Name	:	SHANE ALEXANDER CLARK
Credential	:	OD
Telephone Number	:	605-342-0258

Provider Enumeration Date	:	09/18/2019
Last Update Date	:	09/19/2023

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