Basic Information
| Provider Information | |||||||||
| NPI: | 1497031124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRERICHS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 LAKE PLAZA DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192193819 | ||||||||
| FaxNumber: | 7192190411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 LAKE PLAZA DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192193819 | ||||||||
| FaxNumber: | 7192190411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2011 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1660 | SC | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT 0002957 | CO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.