Basic Information
Provider Information | |||||||||
NPI: | 1629160312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SENSATIONAL EYES VISION CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1280 CENTAUR VILLAGE DR | ||||||||
Address2: | #2 | ||||||||
City: | LAFAYETTE | ||||||||
State: | CO | ||||||||
PostalCode: | 800263175 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036041060 | ||||||||
FaxNumber: | 7208908153 | ||||||||
Practice Location | |||||||||
Address1: | 1280 CENTAUR VILLAGE DR | ||||||||
Address2: | #2 | ||||||||
City: | LAFAYETTE | ||||||||
State: | CO | ||||||||
PostalCode: | 800263175 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036041060 | ||||||||
FaxNumber: | 7208908153 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIMEL | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3036041060 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 1403 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.