1053621367 NPI number — VIRGINIA VISION CARE ASSOC., L.L.C.

Table of content: (NPI 1053621367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053621367 NPI number — VIRGINIA VISION CARE ASSOC., L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIA VISION CARE ASSOC., L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1053621367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 BISHOP ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80521-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-767-1907
Provider Business Mailing Address Fax Number:
303-366-1733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 N TELLURIDE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUCKLEY AFB
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80011-7809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-767-1907
Provider Business Practice Location Address Fax Number:
303-366-1733
Provider Enumeration Date:
10/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLELLAND
Authorized Official First Name:
EWING
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OPTOMETRIST/SOLE MEMBER
Authorized Official Telephone Number:
720-767-1907

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT.0003092 , 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)





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