Basic Information
| Provider Information | |||||||||
| NPI: | 1740314483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE CARE CENTER OF NORTHERN COLORADO, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 DRY CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805036505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037723300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 DRY CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805036505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037723300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 06/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | MEYERS | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3037723300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CN4108 | 01 | CO | MEDICARE GROUP | OTHER | 04018032 | 05 | CO | MEDICAID |