Provider Demographics
NPI:1093958514
Name:WIARDA OPTOMETRY, PLLC
Entity Type:Organization
Organization Name:WIARDA OPTOMETRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:WIARDA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-467-4422
Mailing Address - Street 1:4786 MCMURRY AVE UNIT 2A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4499
Mailing Address - Country:US
Mailing Address - Phone:248-467-4422
Mailing Address - Fax:
Practice Address - Street 1:4786 MCMURRY AVE UNIT 2A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4499
Practice Address - Country:US
Practice Address - Phone:970-204-4020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97237388Medicaid