Provider Demographics
NPI:1043325806
Name:LONGMONT VISION CENTER LLC
Entity Type:Organization
Organization Name:LONGMONT VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-651-6700
Mailing Address - Street 1:412 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5535
Mailing Address - Country:US
Mailing Address - Phone:303-651-6700
Mailing Address - Fax:303-776-9193
Practice Address - Street 1:412 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5535
Practice Address - Country:US
Practice Address - Phone:303-651-6700
Practice Address - Fax:303-776-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1188152W00000X
CO915152W00000X
CO2365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4482420001Medicare NSC
CO380008Medicare PIN