Provider Demographics
NPI:1255509402
Name:SOUTHWEST DENVER EYE CENTER LLC
Entity Type:Organization
Organization Name:SOUTHWEST DENVER EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-948-2020
Mailing Address - Street 1:PO BOX 621986
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80162-1986
Mailing Address - Country:US
Mailing Address - Phone:303-948-2020
Mailing Address - Fax:720-981-4250
Practice Address - Street 1:6179 S BALSAM WAY STE 130
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-3092
Practice Address - Country:US
Practice Address - Phone:303-948-2020
Practice Address - Fax:720-981-4250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28763332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01287630Medicaid
CO01287630Medicaid
CO1188050001Medicare NSC