Provider Demographics
NPI:1033454806
Name:EDGE OPTICS LLC
Entity Type:Organization
Organization Name:EDGE OPTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MASON
Authorized Official - Middle Name:TAMBLYN
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-682-2627
Mailing Address - Street 1:706 S COLLEGE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-9817
Mailing Address - Country:US
Mailing Address - Phone:970-682-2627
Mailing Address - Fax:
Practice Address - Street 1:706 S COLLEGE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-9817
Practice Address - Country:US
Practice Address - Phone:970-682-2627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty