MEDICARE: FAMILY VISION CARE OF PONCA CITY

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	332B00000X	Durable Medical Equipment & Medical Supplies	OK2144	OK
2	332H00000X	Eyewear Supplier	OK2144	OK
3	152W00000X	Optometrist	OK2144	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902000904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY VISION CARE OF PONCA CITY

Provider Business Mailing Address
First Line	:	1619 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2703
Country	:	US
Telephone Number	:	580-762-5700
Fax Number	:	580-765-3022

Provider Business Practice Location Address
First Line	:	1619 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2703
Country	:	US
Telephone Number	:	580-762-5700
Fax Number	:	580-765-3022

Authorized Official
Title or Position	:	OPTOMETRIST OWNER
Name	:	DR. KELLY C CAMPBELL
Credential	:	O.D.
Telephone Number	:	580-762-5700

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	12/30/2016

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