Basic Information
| Provider Information | |||||||||
| NPI: | 1336609957 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOTHILLS EYE CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1530 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804021530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036536255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 952 SWEDE GULCH RD | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804393713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035260534 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2019 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | VINCENT | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3036536255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.