1306146121 NPI number — BALLANTYNE VISION CARE LLC

Table of content: (NPI 1306146121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306146121 NPI number — BALLANTYNE VISION CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALLANTYNE VISION CARE 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:
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:
1306146121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JUNTA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81050-0305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-383-0134
Provider Business Mailing Address Fax Number:
719-404-1825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 W 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JUNTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81050-1430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-383-0134
Provider Business Practice Location Address Fax Number:
719-404-1825
Provider Enumeration Date:
10/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BALLANTYNE
Authorized Official First Name:
JORDAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST, OWNER
Authorized Official Telephone Number:
719-383-0134

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2799 , 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: COA106109 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 93920288 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1306146121 . This is a "NPI FOR LAMAR OFFICE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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