Provider Demographics
NPI:1902587751
Name:LANDER VISION SOURCE PC
Entity Type:Organization
Organization Name:LANDER VISION SOURCE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KORTNY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LANCASTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:307-389-7722
Mailing Address - Street 1:556 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3032
Mailing Address - Country:US
Mailing Address - Phone:307-332-2020
Mailing Address - Fax:307-332-5718
Practice Address - Street 1:556 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3032
Practice Address - Country:US
Practice Address - Phone:307-332-2020
Practice Address - Fax:307-332-5718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty