Basic Information
| Provider Information | |||||||||
| NPI: | 1790741908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE CENTER OPTICAL OF NORTHERN COLORADO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805251307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212222 | ||||||||
| FaxNumber: | 9702214286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805251307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212222 | ||||||||
| FaxNumber: | 9702214286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER SERVICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9702212222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 08769739 | 05 | CO | MEDICAID |