Basic Information
Provider Information | |||||||||
NPI: | 1134374945 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CREATIVE EYEWEAR LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARVADA OPTICAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8850 RALSTON RD | ||||||||
Address2: | #100 | ||||||||
City: | ARVADA | ||||||||
State: | CO | ||||||||
PostalCode: | 800022252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034218990 | ||||||||
FaxNumber: | 3034219402 | ||||||||
Practice Location | |||||||||
Address1: | 8850 RALSTON RD | ||||||||
Address2: | #100 | ||||||||
City: | ARVADA | ||||||||
State: | CO | ||||||||
PostalCode: | 800022252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034218990 | ||||||||
FaxNumber: | 3034219402 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2008 | ||||||||
LastUpdateDate: | 11/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINNOTTE | ||||||||
AuthorizedOfficialFirstName: | DAVE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OPTICIAN | ||||||||
AuthorizedOfficialTelephone: | 3034218990 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PRACTICE ADMIN. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | CO2534 | CO | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 1013027291 | 01 | CO | NPI OPTOMETRIST | OTHER | MP1473076 | 01 | CO | DEA # | OTHER | CO2534 | 01 | CO | COLORADO LISCENCE # | OTHER |