Provider Demographics
NPI:1699047365
Name:PAULS VALLEY EYE CLINIC PLLC
Entity type:Organization
Organization Name:PAULS VALLEY EYE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:B
Authorized Official - Last Name:MENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-238-6459
Mailing Address - Street 1:1811 WEST GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-0622
Mailing Address - Country:US
Mailing Address - Phone:405-238-6459
Mailing Address - Fax:405-238-6450
Practice Address - Street 1:1811 WEST GRANT AVE
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-0622
Practice Address - Country:US
Practice Address - Phone:405-238-6459
Practice Address - Fax:405-238-6450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2662152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6714940001Medicare NSC