Provider Demographics
NPI:1275660565
Name:ARCHDALE OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:ARCHDALE OPTOMETRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE (TED)
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHDALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-638-4010
Mailing Address - Street 1:7095 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6329
Mailing Address - Country:US
Mailing Address - Phone:719-638-4010
Mailing Address - Fax:719-638-4021
Practice Address - Street 1:7095 LEXINGTON DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6329
Practice Address - Country:US
Practice Address - Phone:719-638-4010
Practice Address - Fax:719-638-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1588660161OtherPERSONAL NPI
CO26777312Medicaid
CO08014664Medicaid
COC461248Medicare PIN
CO1588660161OtherPERSONAL NPI
COC461258Medicare PIN
CO08014664Medicaid