Basic Information
| Provider Information | |||||||||
| NPI: | 1376983924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN COLORADO EYE CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 E HAHNS PEAK AVE STE C | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810073662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195423555 | ||||||||
| FaxNumber: | 7195420425 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 E HAHNS PEAK AVE STE C | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810073662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195423555 | ||||||||
| FaxNumber: | 7195420425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 06/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | COZZETTA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7195423555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | CO1347 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.