Provider Demographics
NPI:1275695827
Name:ROCKY MOUNTAIN EYE CENTER INC A COLORADO PROVIDER NETWORK
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN EYE CENTER INC A COLORADO PROVIDER NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-545-1530
Mailing Address - Street 1:27 MONTEBELLO RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1236
Mailing Address - Country:US
Mailing Address - Phone:719-545-1530
Mailing Address - Fax:719-545-2899
Practice Address - Street 1:102 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1523
Practice Address - Country:US
Practice Address - Phone:719-384-8719
Practice Address - Fax:719-384-8738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COROK0008OtherANTHEM BLUE CROSS BLUE SHIELD
CO608439600OtherU S. DEPARTMENT OF LABOR
CO04009478Medicaid
CO608439600OtherU S. DEPARTMENT OF LABOR
COROK0008OtherANTHEM BLUE CROSS BLUE SHIELD
COCQ2139Medicare Oscar/Certification