1871755041 NPI number — BAYFIELD FAMILY EYE CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871755041 NPI number — BAYFIELD FAMILY EYE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYFIELD FAMILY EYE 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:
BAYFIELD FAMILY EYE CARE
Provider Other Organization Name Type Code:
3
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:
1871755041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 WOLVERINE DR
Provider Second Line Business Mailing Address:
# 5
Provider Business Mailing Address City Name:
BAYFIELD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81122-9653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-884-6188
Provider Business Mailing Address Fax Number:
970-884-2869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 WOLVERINE DR
Provider Second Line Business Practice Location Address:
# 5
Provider Business Practice Location Address City Name:
BAYFIELD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81122-9653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-884-6188
Provider Business Practice Location Address Fax Number:
970-884-2869
Provider Enumeration Date:
06/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ZISSMAN
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
970-884-6188

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2532 , 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: 2532 . This is a "COPLORADO OPTOMETRIC LICENSE #" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 267474590 . This is a "PERSONAL SS# FOR JONATHAN E ZISSMAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1396770962 . This is a "PERSONAL NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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