Provider Demographics
NPI:1275523938
Name:NORTHWEST EYECARE CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST EYECARE CENTER, LLC
Other - Org Name:EYECARE SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DANNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-824-3488
Mailing Address - Street 1:1111 W VICTORY WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-2950
Mailing Address - Country:US
Mailing Address - Phone:970-824-3488
Mailing Address - Fax:970-824-8132
Practice Address - Street 1:1111 W VICTORY WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-2950
Practice Address - Country:US
Practice Address - Phone:970-824-3488
Practice Address - Fax:970-824-8132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO848152W00000X
CO1589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04018867Medicaid
CO1471066OtherUMWA
CO0739550001Medicare NSC
COCD6208Medicare UPIN
COCD6208Medicare PIN