Provider Demographics
NPI:1114484656
Name:JENNIFER HAVRILLA LLC
Entity Type:Organization
Organization Name:JENNIFER HAVRILLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRILLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-206-0100
Mailing Address - Street 1:2001 S SHIELDS ST STE J1
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1837
Mailing Address - Country:US
Mailing Address - Phone:970-206-0100
Mailing Address - Fax:970-206-0300
Practice Address - Street 1:2001 S SHIELDS ST STE J1
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1837
Practice Address - Country:US
Practice Address - Phone:970-206-0100
Practice Address - Fax:970-206-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty