Provider Demographics
NPI:1992143648
Name:CLEAR IMAGE LASER STUDIO
Entity type:Organization
Organization Name:CLEAR IMAGE LASER STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MOSHER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:307-259-2434
Mailing Address - Street 1:532 VAL VISTA ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3655
Mailing Address - Country:US
Mailing Address - Phone:307-655-8289
Mailing Address - Fax:307-655-8291
Practice Address - Street 1:532 VAL VISTA ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3655
Practice Address - Country:US
Practice Address - Phone:307-655-8289
Practice Address - Fax:307-655-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9206-1081261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care