1275523938 NPI number — NORTHWEST EYECARE CENTER, LLC

Table of content: (NPI 1275523938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275523938 NPI number — NORTHWEST EYECARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST EYECARE CENTER, LLC
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:
6
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:
1275523938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 W VICTORY WAY
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
CRAIG
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81625-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-824-3488
Provider Business Mailing Address Fax Number:
970-824-8132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 W VICTORY WAY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
CRAIG
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81625-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-824-3488
Provider Business Practice Location Address Fax Number:
970-824-8132
Provider Enumeration Date:
10/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DANNER
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER / MANAGER
Authorized Official Telephone Number:
970-824-3488

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  848 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 1589 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 04018867 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1471066 . This is a "UMWA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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