1750411062 NPI number — ROCKY MOUNTAIN EYE CENTER INC A COLORADO PROVIDER NETWORK

Table of content: (NPI 1750411062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750411062 NPI number — ROCKY MOUNTAIN EYE CENTER INC A COLORADO PROVIDER NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY MOUNTAIN EYE CENTER INC A COLORADO PROVIDER NETWORK
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:
1750411062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 MONTEBELLO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81001-1236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-545-1530
Provider Business Mailing Address Fax Number:
719-545-2899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87740-2032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-445-2789
Provider Business Practice Location Address Fax Number:
575-445-2780
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HULETT
Authorized Official First Name:
ANN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
719-545-1530

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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: 200521004 . This is a "MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM007E27 . This is a "BCBS NEW MEXICO GROUP #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85707368 . This is a "NEW MEXICO MEDICAID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: CK7367 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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