1730387374 NPI number — MISS RACHEL AMELIA POTTER O.D.

Table of content: MISS RACHEL AMELIA POTTER O.D. (NPI 1730387374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730387374 NPI number — MISS RACHEL AMELIA POTTER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTER
Provider First Name:
RACHEL
Provider Middle Name:
AMELIA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730387374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2829 PRINCE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80516-7536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-945-6828
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2080 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGMONT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80501-1916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-651-2020
Provider Business Practice Location Address Fax Number:
303-776-2460
Provider Enumeration Date:
07/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT-2591 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 85605590 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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