Provider Demographics
NPI:1487716668
Name:SCOTTSBLUFF VISION CLINIC P C
Entity type:Organization
Organization Name:SCOTTSBLUFF VISION CLINIC P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLBURN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-532-2060
Mailing Address - Street 1:520 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1517
Mailing Address - Country:US
Mailing Address - Phone:307-532-2060
Mailing Address - Fax:307-532-5710
Practice Address - Street 1:520 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1517
Practice Address - Country:US
Practice Address - Phone:307-532-2060
Practice Address - Fax:307-532-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY193T152W00000X
WY316T152W00000X
WY174T152W00000X
WY123T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0027001OtherBCBS WY SUBMITTER ID
WY102711500Medicaid
WY0312350002Medicare NSC
WYW4591089Medicare PIN