Basic Information
| Provider Information | |||||||||
| NPI: | 1164416947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REPINE VISION AND LASER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COUNTY LINE OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8381 SOUTHPARK LN | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801204508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037308024 | ||||||||
| FaxNumber: | 3037306163 | ||||||||
| Practice Location | |||||||||
| Address1: | 8381 SOUTHPARK LN | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801204508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037308024 | ||||||||
| FaxNumber: | 3037306163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | NORA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPTICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3037308024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REPINE VISION AND LASER LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 40376 | 01 | BLUE CROSS CLUE SHIELD | OTHER | 55800068 | 05 | CO | MEDICAID |