Provider Demographics
NPI:1205977394
Name:NORTH EAST FAMILY EYECARE PC
Entity type:Organization
Organization Name:NORTH EAST FAMILY EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-244-2889
Mailing Address - Street 1:200 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2402
Mailing Address - Country:US
Mailing Address - Phone:903-244-2889
Mailing Address - Fax:918-567-3240
Practice Address - Street 1:200 DALLAS ST
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2402
Practice Address - Country:US
Practice Address - Phone:903-244-2889
Practice Address - Fax:918-567-3240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6474TG152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA102212Medicare PIN