1548254881 NPI number — REPINE VISION AND LASER PROFESSIONAL LLC

Table of content: (NPI 1548254881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548254881 NPI number — REPINE VISION AND LASER PROFESSIONAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REPINE VISION AND LASER PROFESSIONAL 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:
1548254881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8381 SOUTHPARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80120-4508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-788-8848
Provider Business Mailing Address Fax Number:
303-730-6163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8381 SOUTHPARK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLETON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80120-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-788-8848
Provider Business Practice Location Address Fax Number:
303-730-6163
Provider Enumeration Date:
09/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REPINE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-788-8848

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 40376 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 55800068 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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