1386875441 NPI number — FOUR CORNERS EYE CLINIC, PC

Table of content: (NPI 1386875441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386875441 NPI number — FOUR CORNERS EYE CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR CORNERS EYE CLINIC, PC
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:
1386875441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
575 RIVERGATE LANE
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-259-2202
Provider Business Mailing Address Fax Number:
970-259-2837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 TALISMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAGOSA SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81147-9171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-259-2202
Provider Business Practice Location Address Fax Number:
970-259-2837
Provider Enumeration Date:
08/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MEYER
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-259-2202

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  39400 , 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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