Provider Demographics
NPI:1235130303
Name:MOUNTAIN VIEW OPTICAL LLC
Entity Type:Organization
Organization Name:MOUNTAIN VIEW OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:303-467-3025
Mailing Address - Street 1:4350 WADSWORTH BLVD
Mailing Address - Street 2:STE 320
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4634
Mailing Address - Country:US
Mailing Address - Phone:303-467-3025
Mailing Address - Fax:303-423-5818
Practice Address - Street 1:4350 WADSWORTH BLVD
Practice Address - Street 2:STE 320
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4641
Practice Address - Country:US
Practice Address - Phone:303-467-3025
Practice Address - Fax:303-423-5818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO05483680000332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0950650001Medicare NSC