Provider Demographics
NPI:1427265180
Name:EYE CARE CLINIC & OPTICAL LLC
Entity type:Organization
Organization Name:EYE CARE CLINIC & OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-778-2771
Mailing Address - Street 1:6228 YELLOWSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3432
Mailing Address - Country:US
Mailing Address - Phone:307-778-2771
Mailing Address - Fax:307-634-5443
Practice Address - Street 1:6228 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3432
Practice Address - Country:US
Practice Address - Phone:307-778-2771
Practice Address - Fax:307-634-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106507600Medicaid
WY5408440001Medicare NSC
WY106507600Medicaid