Provider Demographics
NPI:1215012091
Name:KINGFISHER EYE CLINIC INC
Entity type:Organization
Organization Name:KINGFISHER EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER OF CORPORATION SECRETARY TR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:REICHERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-262-2354
Mailing Address - Street 1:824 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-3625
Mailing Address - Country:US
Mailing Address - Phone:405-375-5994
Mailing Address - Fax:405-375-5952
Practice Address - Street 1:824 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-3625
Practice Address - Country:US
Practice Address - Phone:405-375-5994
Practice Address - Fax:405-375-5952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherVSP
OK0200130001Medicare NSC
OK=========Medicare PIN