Basic Information
| Provider Information | |||||||||
| NPI: | 1548254881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REPINE VISION AND LASER PROFESSIONAL LLC | ||||||||
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| OtherOrganizationName: | REPINE VISION AND LASER LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8381 SOUTHPARK LN | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801204508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037888848 | ||||||||
| FaxNumber: | 3037306163 | ||||||||
| Practice Location | |||||||||
| Address1: | 8381 SOUTHPARK LN | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801204508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037888848 | ||||||||
| FaxNumber: | 3037306163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | REPINE | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3037888848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 40376 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 55800068 | 05 | CO | MEDICAID |